(091) 530054
info@GalwayBayMedicalCentre.ie

Fertility Clinic – PreConsult Questionnaire – Female

Personal Details

DD slash MM slash YYYY

Medical History

Have you ever had an abnormal smear?(Required)
Do you have any of the following Gynaecological problems?(Required)
How often, when did your last one start? How many days do they last? How heavy?
Have you ever had any of the following?(Required)
Have you been diagnosed with any medical conditions?(Required)
Are there any significant medical or genetic issues in your family?(Required)
Do you have any medical issues or symptoms at present?(Required)

Lifestyle

Do you smoke cigarettes or Vape?(Required)
Do you drink alcohol?(Required)
Have you taken recreational drugs in the last year?(Required)
Do you ever feel stressed, anxious or depressed
Is your bodyweight in the healthy range?(Required)
Do you have a healthy diet?(Required)
Do you get plenty of exercise?(Required)
Have you ever conceived with either your current or a previous partner?(Required)

Sexual Health

Have you had any sexually transmitted infections in the past?(Required)
Do you get discomfort or other difficulties with sex?(Required)
Do you have sex often enough to conceive (every 2-3 days)(Required)
Do you use lubrication?(Required) Can cause sperm trapping…
Is a delay in becoming pregnant causing you stress(Required)
Have you used ovulation test kits?(Required)
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