Hypnotherapy Intake Form – Fertility Please enable JavaScript in your browser to complete this form.PERSONAL DETAILSName *FirstLastAddressAddress Line 1Address Line 2CityState / Province / RegionPostal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwan, Province of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)Viet NamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryPhoneDate of BirthAgeOccupationPartner's Name *FirstLastMarital StatusHow 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 PRACTITIONERDoctor's Name (GP) *FirstLastDoctor's AddressAddress Line 1Address Line 2CityState / Province / RegionPostal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwan, Province of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)Viet NamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryDoctor's PhoneFertility ClinicConsultant Name *FirstLastFERTILITY HISTORYHave you seen a GP regarding your fertility?YesNoWhat diagnosis did you receive?How long have you been trying for a baby?Have you ever been pregnant?YesNoHow long did it take to fall pregnant the first time?Did you fall pregnant naturally?YesNoIf '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?YesNoIf '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?YesNoHave you ever had a termination?YesNoIf 'Yes' to the above, is this termination confidential?YesNoFERTILITY TREATMENTWhat 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 HEALTHHave you ever used any form of contraception?YesNoIf '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?YesNoCurrently 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?YesNoDo you experience any pre-menstrual symptoms? Please provide details.What sanitary products do you use?Do you ovulate every month?YesNoHow do you know when you are ovulating?Are you aware of your fertile time?YesNoHave you ever been diagnosed with:PCOSEndometriosisFibroidsGynaecological ProblemsRELATIONSHIPDo you experience any difficulties in your sexual relationship?YesNoHas trying for a baby affected your sex life?YesNoHow frequently do you have sex?FAMILY HISTORY Is there any history or fertility problems in your family?YesNoIf 'Yes' to the above, please provide details.Is there any history of birth trauma in your family?YesNoIf 'Yes' to the above, please provide details.Do you know if your own birth was traumatic?YesNoIf 'Yes' to the above, please provide details. Are your parents still alive?YesNoAre your parents still married?YesNoHow many brothers and/or sisters do you have?What is your position among your siblings?Do any of your siblings have children?YesNoMENTAL HEALTHHave you ever experienced anxiety or depression?YesNoIf 'Yes' to the above, please provide details?Have you ever struggled with addiction?YesNoIf 'Yes' to the above, please provide details? PHYSICAL HEALTHHow 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?YesNoDo you smoke?YesNoDo you drink alcohol?YesNoIf 'Yes' to the above how many units per week?Do you take recreational drugs?YesNoHow many hours a week do you work?What do you do to relax?WeightHeightAny 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?CommentSubmit