Medical History Form

1Patient Personal Details

2Medical Conditions, Surgeries & Medications

3Female Specific Information

4Male Specific Information

5Allergies & Social Risks

Name*

First Last

Date of Birth*

DD slash MM slash YYYY

Gender*

Please select your gender at birth

Female

Male

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Approximately when did you start trying to conceive?

(estimate month & year started)

Height (cm)

Weight (kg)

Do you have a partner?*

Yes

Partner's Details

Partner Name

Please enter partners name if applicable

First Last

Partners Date of Birth

Enter if applicable

DD slash MM slash YYYY

Partner's Gender*

Please select gender at birth

Female

Male

Past Medical Conditions

Please select all that apply

Heart Disease

High / Low Blood Pressure

Thyroid Condition

Epilepsy / Seizures

Hepatitis

Shortness of Breath

Blood Clots

Diabetes

Asthma

Other Medical Condition(s)

Medical Conditions further details

Have you had any surgerical procedures?

Yes

Past Surgeries

Please give details of any past surgeries including year and type of procedure ie ... 2018 - HSG, Laparoscopy etc.

Surgery Complications

Please describe any complications ie vomiting after anaesthetic

Current Medications

Do you currently take any medications including non-prescription drugs such as folate & iodine?

Yes

Medication Details

Please give details of all medications your are currently taking including name, dose and frequency.

Female Specific Information

Date of Last Menstrual Period (LMP)

DD slash MM slash YYYY

Average Cycle Length

Average number of days in your cycle

Minimum Cycle Length

Minimum number of days in your cycle

Maximum Cycle Length

Maximum number of days in your cycle

Date of Last Pap Smear

DD slash MM slash YYYY

Pap Smear Results

ie Normal

Have you ever been pregnant?

Yes

Pregnancy Details

Pregnancies with Current Partner

Enter number in appropriate box(es)

Full Term (>37 weeks)

Pre-Term (<37 weeks)

Biochemical

Miscarriage (<12 weeks)

Miscarriage (12-20 weeks)

Termination

Ectopic

Pregnancies with Previous Partner

Enter number in appropriate box(es)

Full Term (>37 weeks)

Pre-Term (<37 weeks)

Biochemical

Miscarriage (<12 weeks)

Miscarriage (12-20 weeks)

Termination

Ectopic

Details of Babies Delivered

Born after 20 weeks

Date

Conception Type (ie natural, ivf or insemination)

Outcome (ie Live Birth, Still Birth)

Delivery (ie c-section, natural)

Gender

Name

Previous Fertility Treatment

Please give details of any other Fertility treatment you've had at any other clinic

Year

Clinic

Treatment Type (ie IVF, PGD)

Outcome (ie cancelled, biochemical, pregnant etc)

Male Specific Information

Do you have children with your current partner?

Yes

Do you have children with a previous partner?

Yes

Details of Children born to Previous Partner Only

Do not include children born to your current partner

Date

Conception Type (ie natural, ivf or insemination)

Outcome (ie Live Birth, Still Birth)

Delivery (ie c-section, natural)

Gender

Name

Date of Last Semen Analysis

Where did you have the Semen Analysis?

Name of Pathology Centre or Clinic

Do you have any problems with ejaculation

If yes, please request to speak with a nurse

Yes

Do you foresee any problems using our on-site collection room?

Is yes, please request to speak with a nurse

Yes

Allergies & Social Risks

Do you have any allergies

(including allergies to sticking plaster or latex)

Yes

Please give details of Allergies

Date start (approx)

Allergy

Reaction type: Mild, Moderate, Severe, Anaphylaxis

Do you or have you ever smoked?

Yes

Number of cigarettes / day?

If you have quit smoking, please give the cease date (approx)

Do you drink caffeine?

Yes

Number of cups / day

Do you drink Alcohol?

Yes

Number of glasses / week

Do you take any non-prescription drugs

ie recreational drugs (ie marijuana), sedatives etc

Yes - currently

Yes - in the past

Non-Prescription Drugs

Drug Type

Current or Past Use?

Partner's Details

Female Specific Information

Pregnancy Details

Male Specific Information

Allergies & Social Risks

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