Confidential Health Questionnaire Confidential Health QuestionnaireΔ Please fill in all of the following and return to me via email. If there is anything that you can’t answer or is not applicable to you then just leave it blank. It will take a while but the more details that I have the better I will be able to help. I need to build up a complete picture of you, so be as specific as you can be. It is in 2 parts, the female and then the male partner. There are some general questions at the end. This is completely confidential & no one except for me will see it. I spend all day listening or reading people’s stories- nothing surprises me so feel free to give as many details as you can under all of the headings. 1.Can you tell me please how you heard about this service? (eg article, website, referral from a friend or health professional, google search?)Female PartnerNameAddressEmailPhone/MobileDate of BirthHeightWeightBMIBlood group (if known)Usual BP (if known)Please rate on a scale of 1 (low) to 10 (high)Energy levels0Stress levels0Happiness0PreviousNextTell me first why you are doing this program. What is your story with fertility so far (please give me as many details as possible including the general details of fertility treatment such as how many eggs were retrieved and how many embryos developed/transferred)What do you hope to achieve from this program?Have you ever been pregnant? If so, when & what was the outcome? Include any miscarriages or any times you think you may have been pregnant (leave blank if you have already answered)Have you had any fertility tests done?What contraception have you used in the past and for how long?Are you having any treatment at the moment or have you in the past for fertility? Include natural treatments as well as medical ones.How would you describe your general health?How was your mothers pregnancy with you?How was your birth?Any health problems now or in the past? Please give as much information as you can about your health issues, periods of emotional stress / trauma and significant incidents in your life such as periods of stress, accidents, bereavements. Anything at all- not necessarily relating to reproductionPrescription drugs – What medications are you taking at the moment or have you taken in the past?Allergies and Sensitivities – Describe any allergies or food reactions that you experienceAny family medical history with your parents, siblings etc. Anybody been diagnosed with anything, even cousins, aunts, uncles etc?Occupation/employment, what kind of work do you do now & what have you done in the past.Does your work cause you any stress? If so, in what way?Tell me about your menstrual cycle- this is very important so give as many details as you can.How often do you get you period? (eg every 28, 30, 40 days) If you know your last few cycle lengths, please include, starting from most recent. (eg 27, 29, 26, 32, 28)Do you get any premenstrual symptoms, either physical or emotional? How many days do these last?How many days does your period last for & do you get any unusual symptoms with it?Is it any different now to in the past, like when you were younger or before fertility drugs/ contraception / a pregnancy?Describe any pain or other symptoms that you get at this timeAre you aware that you ovulate? What symptoms do you get? (eg cervical mucus, pain or discomfort, increased libido, abdominal bloating)Have these symptoms changed over the last few months or years?What days of your cycle do you usually detect ovulation?Do you use anything to predict ovulation? (eg blood tests, test kits, temperature charting etc)PreviousNextDescribe your general eating patternBreakfastLunchDinnerBetween mealsDrinksTeaCoffeeWaterSoda/fizzy drinksJuiceAlcoholAny foods you avoid or crave?Any other substances eg recreational drugs, cigarettes etc?Do you take any nutritional supplements?Would you describe your lifestyle as sedentary, moderately active or active?Do you eat organic food?Do you drink filtered water?Do you regularly use computers? If yes, how many hours a day?How would you describe your weight, has this changed much over the last few years?Any areas of stress in your life?Any major periods of stress in the past?How would you say your fertility challenges have affected you?How are your relationships with others- friends, workmates, etc. Any areas of conflict now or in the past?Medical tests – Please give results of any investigations i.e.: xrays, MRI’s etc…Medical procedures – Have you had major surgery, dental surgery, broken bones, root canals , mercury fillings etc.Do you use any chemicals in the home such as cleaning products? Do you regularly use mobile phones, microwaves?Do you have any electrical appliances in your bedroom?Do you have any fears (dark, heights, spiders, thunderstorms, fairgrounds, tunnets, flying etc.)Any major traumatic / life changing events in your life? This may be loss, injury, big change, shocking events, witnessing trauma, divorces etc…PreviousNextTemperament / CharacterPlease write me a detailed description of yourselfAre you tidy / organised?What irritates you?Ambitions?Hobbies? If you like to read, listen to music, watch films etc. then what type?What do you like to do socially?Do you enjoy your own company?Are you someone who shares your worries or do you prefer to keep them to yourself?Mood swings? Do you get depressed?What makes you cry?Relationships with your parents, siblings, partner, children?Any bereavements?Do you enjoy your work?Please let me as much as you can about your personality...SubmitPreviousNextMale PartnerNamePhone/MobileDate of BirthHeightWeightBMIBlood group (if known)Usual BP (if known)Please rate on a scale of 1 (low) to 10 (high)Energy0Stress levels0Happiness0PreviousNextWhat do you hope to achieve from this program?Have you had any specific fertility tests done? If you have any results from a Semen Analysis please put them here or attach in an emailChoose File Are you having any treatment for anything at all at present?How would you describe your general health?Any health problems now or in the past? Anything at all, not necessarily relating to reproductionAny family medical history with your parents, siblings etc. Anybody been diagnosed with anything, even cousins, aunts, uncles etc?Occupation/employment, what kind of work do you do now & what have you done in the past.Does your work cause you any stress? If so, in what way?Describe your general eating pattern BreakfastLunchDinnerBetween mealsDrinksTeaCoffeeWaterSoda/fizzy drinksJuiceAlcoholAny foods you avoid or crave?Any other substances, eg recreational drugs, cigarettes etc?Do you take any nutritional supplements?Would you describe your lifestyle as sedentary, moderately active or active?Do you eat organic food?Do you drink filtered water?PreviousNextDo you regularly use computers? If yes, how many hours a day?How would you describe your weight, has this changed much over the last few years?Any areas of stress in your life?Any major periods of stress in the past?How would you say your fertility challenges have affected you?How are your relationships with others- friends, workmates, etc. Any areas of conflict now or in the past?Medical tests – Please give results of any investigations i.e.: xrays, MRI’s etc…Medical procedures – Have you had major surgery, dental surgery, broken bones, root canals , mercury fillings etc.Do you use any chemicals in the home such as cleaning products or with your work? Do you regularly use mobile phones, microwaves?Temperament / CharacterPlease write me a detailed description of yourselfDo you have any electrical appliances in your bedroom?Do you have any fears (dark, heights, spiders, thunderstorms, fairgrounds, tunnets, flying etc.)Any major traumatic / life changing events in your life?This may be loss, injury, big change, shocking events, witnessing trauma, divorces etc… PreviousNextAre you tidy / organised?What irritates you?Ambitions? Hobbies? If you like to read, listen to music, watch films etc. then what type?What do you like to do socially?Do you enjoy your own company?Are you someone who shares your worries or do you prefer to keep them to yourself?Mood swings? Do you get depressed?What are you like emotionally?Relationships with your parents, siblings, partner, children?Any bereavements?Do you enjoy your work?Please let me as much as you can about your personality….PreviousNextIs there anything else at all you think would be helpful to tell me about either of you?Have either of you used homeopathic remedies in the past?Do either of you have anything in particular you would like covered during your Initial consultation? SubmitThank you for filling this out. I will get back to you if I need any further information. Cassie Everett LCHE BA HonsHomeopath and Natural Fertility Specialist Cassieeverett.com07588 820 409 Previous
