Suite 14A, Corporate One, Corporate Court, Bundall Qld 4217
(07) 5667 7711
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Fertility Services
Fertility Assessment
Male Fertility Assessment
Oocyte Freezing
Donor Services
In-Vitro Fertilisation (IVF)
Ovulation Induction
Intrauterine Insemination
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Endometriosis
Hormonal IUD
Polycystic Ovaries and Health
Cervical Screening and Colposcopy
Menopause Therapy and Management
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Menu
Home
Fertility Services
Fertility Assessment
Male Fertility Assessment
Oocyte Freezing
Donor Services
In-Vitro Fertilisation (IVF)
Ovulation Induction
Intrauterine Insemination
Gynaecology
Endometriosis
Hormonal IUD
Polycystic Ovaries and Health
Cervical Screening and Colposcopy
Menopause Therapy and Management
Articles
About
Contact
Fertility Questionnaire
Have you ever been pregnant?
No (Click 'Skip' for next question)
Yes (Complete below)
Pregancies with partner
No
Yes
Child: Female
Child: Male
Miscarriages
Pregancies with other partner/s
No
Yes
Child: Female
Child: Male
Miscarriages
Have you had fertility treatment previously?
No (Click 'Next' to continue)
Yes (complete below)
Types of Treatment
Ovulation Induction (OI)
Intrauterine Insemination (IUI)
Egg Freezing
In-Vitro Fertilisation (IVF)
Allergies to Medications
No
Yes
Details
Do you have any medical conditions or regular medications?
No (click 'Next' to continue)
Yes (Complete below)
Current Medications
Do you have any of these Medical Issues?
Arthritis
Bowel disorders
Cancer
Diabetes
Genetic Concerns
Heart Conditions
Hepatitis
Other liver problems
High Blood Pressure
Lung or Respiratory
Thyroid
Neurological (inc epileps)
Spinal
Skin Disroders
Thalassaemia
Sickle Cell Disease
Tuberculosis
If Yes or other conditions, please provide some details
Have you had operations on pelvis or abdomen?
No (click 'Next')
Yes (complete below)
Obstetric Procedures
D&C (Curette or termination)
Caesarean Section
Cervical cerclage
Ectopic pregnancy
Pelvis/reproductive Operations
Laparoscopy
Hysterectomy
Hysteroscopy
Cervical Surgery
One or both ovaries removed
One or both tubes removed
Operations in abdomen/chest
Appendix
Bladder
Bowel
Kidneys
Liver
Lung
Mastectomy
Details or other procedures
Have you ever had a period?
No (Click 'Next' to continue)
Yes (complete below)
Approximate age at first period
My last period was (months ago)
< 2 months
3 to 6 months
7 to 12 months
> 12 months
Are your periods regular (on time)
No
Yes
Sometimes
Not sure
Would you say your periods are painful?
No
Occasionally
Always
Not sure
Would you say your periods are heavy?
No
Occasionally
Always
Not sure
Submit
Please complete our fertility questionnaire before your appointment
General Medical History
Do you have or had any of the following
(07) 5667 7711
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