Hypnotherapy Intake Form – Fertility

PERSONAL DETAILS

Name *

First

Last

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone

Date of Birth

Age

Occupation

Partner's Name *

First

Last

Marital Status

How long have you been together?

If you have already have a child/children please provide age and date of birth. (Please also include any step children).

MEDICAL PRACTITIONER

Doctor's Name (GP) *

First

Last

Doctor's Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Doctor's Phone

Fertility Clinic

Consultant Name *

First

Last

FERTILITY HISTORY

Have you seen a GP regarding your fertility?

Yes
No

What diagnosis did you receive?

How long have you been trying for a baby?

Have you ever been pregnant?

Yes
No

How long did it take to fall pregnant the first time?

Did you fall pregnant naturally?

Yes
No

If 'No' to the above, please indicate what fertility assistance or treatment you received.

What was the outcome of this pregnancy?

If relevant, what was your birth experience?

Have you ever experienced a miscarriage?

Yes
No

If 'Yes' to the above, please state when and at what stage of pregnancy?

If 'Yes' to the above, did you receive a medical diagnosis regarding the reason for miscarriage.

Have you ever experienced an unwanted pregnancy scare?

Yes
No

Have you ever had a termination?

Yes
No

If 'Yes' to the above, is this termination confidential?

Yes
No

FERTILITY TREATMENT

What tests/investigations have you had regarding fertility e.g. FSH/Progesterone/Scans. Please note down all results.

What medical treatments have you had for fertility e.g IUI, IVF, Clomid etc. Please note down date/treatment type/outcome.

What complimentary treatments have you had for fertility e.g. acupuncture, reflexology etc.

What are your next planned steps including approximate dates if undergoing IUI/IVF etc.

MENSTRUAL HEALTH

Have you ever used any form of contraception?

Yes
No

If 'Yes' to the above, what did you use and for how long?

At what age did you start your period?

What was this experience like for you?

Have you ever experienced irregular cycles?

Yes
No

Currently how long is each cycle?

How many days does your period last for?

Is your period light, average or heavy?

Are your periods ever painful?

Yes
No

Do you experience any pre-menstrual symptoms? Please provide details.

What sanitary products do you use?

Do you ovulate every month?

Yes
No

How do you know when you are ovulating?

Are you aware of your fertile time?

Yes
No

Have you ever been diagnosed with:

PCOS
Endometriosis
Fibroids
Gynaecological Problems

RELATIONSHIP

Do you experience any difficulties in your sexual relationship?

Yes
No

Has trying for a baby affected your sex life?

Yes
No

How frequently do you have sex?

FAMILY HISTORY

Is there any history or fertility problems in your family?

Yes
No

If 'Yes' to the above, please provide details.

Is there any history of birth trauma in your family?

Yes
No

If 'Yes' to the above, please provide details.

Do you know if your own birth was traumatic?

Yes
No

If 'Yes' to the above, please provide details.

Are your parents still alive?

Yes
No

Are your parents still married?

Yes
No

How many brothers and/or sisters do you have?

What is your position among your siblings?

Do any of your siblings have children?

Yes
No

MENTAL HEALTH

Have you ever experienced anxiety or depression?

Yes
No

If 'Yes' to the above, please provide details?

Have you ever struggled with addiction?

Yes
No

If 'Yes' to the above, please provide details?

PHYSICAL HEALTH

How many hours on average do you sleep at night?

What are your exercise interests/habits?

Please provide details of your diet.

Have you seen a nutritionist?

Yes
No

Do you smoke?

Yes
No

Do you drink alcohol?

Yes
No

If 'Yes' to the above how many units per week?

Do you take recreational drugs?

Yes
No

How many hours a week do you work?

What do you do to relax?

Weight

Height

Any other additional health problems?

Are you taking any medications. Please include any supplements, remedies or herbs.

Please outline any fears, concerns or anxieties you may have around becoming pregnant?