Patient Self-Historyquestionnaire

Patient Self-History

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questionnaire

Welcome to the Fertility & Reproductive Medicine Clinic, Bristol

In order that we can understand more about your concerns and provide you with the most appropriate advice, we ask that you to

complete the relevant pages and bring this with you to your clinic appointment.

You can also email this form to us in advance of your appointment if you wish.

If you have any questions or difficulties concerning this Questionnaire/ Form or your Appointment, please contact:

Phone: 0117 4146888

Email: info@bcrm.org.uk

Fax: 0117 4146899

If your clinic appointment is not convenient for you, do let us know so that we can reschedule and offer someone else your time slot.

Thank you and we look forward to seeing you.

Valentine Akande

Date 20

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We may need to contact you about appointment and clinical information, please indicate below which methods of communication

are acceptable to you.

Tick if appropriate contact details [if different from details on page 3]

FEMALE PARTNER

Telephone call/ answering machine message

Text Message (SMS)

Email

Other

MALE/FEMALE PARTNER

Telephone call/ answering machine message

Test Message (SMS)

Email

Other

It is our policy to provide reasonable adjustments or specialised support for people who need them, to enable you to access our

services more effectively. Please complete this section below:

TICK DETAILS

Physical impairment

e.g. a wheelchair user, crutches

Sensory impairment

e.g. deaf/hearing impairment, blind

Mental health issues

e.g. depression, mood disorder, anxiety

Learning disability

e.g. autism spectrum disorder, Downs

Long standing condition / other

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FEMALE (to be completed by the female patient)

Surname First name

Age Date of birth

Are you married No Yes Current address

Postcode

Telephone Other Tel. No.

Occupation Email

Your GP Name GP Tel. No.

GP address

Postcode

Have you attended a Hospital before in the Bristol area? No Yes How long have you been together with you partner?

For how long have you been trying for a pregnancy?

When did you stop using contraception?

Have you ever been pregnant? No Yes If yes, have you conceived any pregnancies in current relationship? No Yes If yes, have, you conceived any pregnancies in any past relationship? No Yes If you have had any pregnancies please answer the following:

Have you had any children? No Yes Have you had any miscarriages? No Yes Have you had any ectopic pregnancies? No Yes Have you had any termination of pregnancies? No Yes

Please give details of all pregnancies in the box below:

Year Fertility treatment (yes/no) Outcome of pregnancy For clinic use

1.

2.

3.

4.

5.

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MENSTRUAL HISTORY

At what age did you start your periods? When was 1st day of your last period?

Are you periods regular? No Yes How many days between period Min. Max.

(ie 1st day of one to the 1st day of the next period)

How many days do you bleed for?

Do you bleed in-between periods? No Yes Do you feel your periods are heavy? No Yes Do you experience pain with periods? No Yes Do you take pain killers during a period? No Yes GYNAE HISTORY

Have you ever had any gynaecological treatment? No Yes Have you been seen in a STD or GUM Clinic? No Yes Have you ever had any genital infections? No Yes Do you have an abnormal vaginal discharge? No Yes Have you had any treatment to your cervix? No Yes Do you experience pain during intercourse? No Yes How many time a month do you have intercourse?

Do you experience bleeding after intercourse? No Yes Do you notice “mid-cycle” mucus discharge? No Yes Do you specially time intercourse? No Yes Do you feel you have more facial hair than normal? No Yes Do you frequently get spots on your face? No Yes SOCIAL HISTORY

Do you smoke? No Yes Alcohol? No Yes Have you injected drugs? No Yes Other drugs? No Yes Have you had any of the following illnesses:

Diabetes Chest problems Bowel problems Hepatitis/ HIV

MEDICAL, SURGICAL & DRUG HISTORY

Have you or your family suffered a thrombosis? No Yes Do you suffer from any illness? No Yes Have you had any operations? No Yes Are you taking any medication? No Yes Are you using any complimentary therapies? No Yes Are you using any herbal or alternative treatment? No Yes

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Do you have allergies (e.g. medication)? No Yes Have you visited your GP in the last year? No Yes Have you suffered from depression? No Yes Have you ever required any psychiatric treatment? No Yes Do you suffer from any of the conditions listed below:

• Irritable bowel, constipation, diarrhoea? No Yes • Water infections, kidney, bladder problems? No Yes • Hot flushes, night sweats? No Yes • Breast discharge, breast lumps? No Yes FAMILY HISTORY

Have any of your relatives suffered from the any of the medical condition listed below:

• Diabetes No Yes • Fertility problems No Yes • Thrombosis No Yes • Miscarriages No Yes • Genetic abnormality No Yes • Early menopause No Yes What is your weight? What is your height?

Is you weight stable? No Yes Do you undertake regular exercise? No Yes Please tick what best describes your diet? Mixed Vegetarian Other Are you taking folic acid? No Yes Is there any other information that you feel is relevant? e.g. operations, medication, therapy, family or non medical history:

I confirm that the information I have provided is accurate:

Name Date

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PARTNER (to be completed by the male partner only if applicable)

Surname First name

Age Date of birth

Are you married No Yes Gender

Current address

Postcode

Telephone Other Tel. No.

Occupation Email

Your GP Name GP Tel. No.

GP address

Postcode

Have you fathered any pregnancies before? No Yes Have you fathered pregnancies in this relationship? No Yes Do travel away from home often? No Yes Does your job expose you to any of the following:

Heat Chemicals Pesticides Radiation

Have you had fertility investigations in the past? No Yes

Do you smoke? No Yes

Have you ever had twisting of a testicle? No Yes Have you injected? No Yes Have you had mumps? No Yes Have you been seen in a STD or GUM Clinic? No Yes Have you ever had any genital infections? No Yes

Do you smoke? No Yes Alcohol? No Yes Have you injected drugs? No Yes Other drugs? No Yes Have you had any of the following illnesses:

Diabetes Chest problems Colitis Hepatitis/ HIV

Any other illnesses? No Yes Have you had any operations? No Yes Are you using any complimentary therapies? No Yes Are you taking any medication? No Yes Do you have any allergies? No Yes Had any mild illnesses during the past 3 months? No Yes

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Do you have difficulty/problems with intercourse as listed below?

• Erection No Yes • Ejaculation No Yes • Penetration No Yes • Pain No Yes Are any of the following relevant, or do you have exposure to any of the following?

• Regular cycling/ exercise No Yes • Radiation No Yes

• Toxins No Yes • Long distance driving No Yes

Do any of your relatives suffer from the following conditions?

• Fertility problems No Yes • Cystic fibrosis No Yes • Genetic abnormality No Yes • Other condition No Yes Is there any other information that you feel is relevant?

I confirm that the information I have provided is accurate:

Name Date

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WHAT HAPPENS AT YOUR FIRST APPOINTMENT?

Many couples have anxieties about attending the clinic for the first time, and we hope that the following will help you:

• Your appointment will be in one of the consulting rooms at Southmead Bristol Hospital in the Wallace wing

• When you arrive check in at reception, you will be directed to a waiting area until you are called in to see your specialist.

• The specialist will ask you questions which could involve sensitive information about periods, timing of sexual intercourse or

previous insemination and to clarify some of the information written in your self history questionnaire.

• A transvaginal ultrasound scan is usually undertaken at the first visit with a chaperone present. The male partner may also be

examined.

• Results of tests will be discussed and advice on how to improve your chances of conceiving will be given. A plan will be made for

further tests and/or starting appropriate treatment.

• If there is anything you do not understand during the consultation please let us know.

Other information that may be helpful

We try to complete the investigations in as short a time as possible, but unfortunately some are more complex and can only be done

at certain times in the monthly cycle. Others involve measuring hormone levels or genetic tests and the results come through in

weeks not days.

Many of the tests can be undertaken at your GP surgery, any tests undertaken at Southmead will need to be paid for.

In general a problem will be identified in approximately 4 out of 5 couples who seek help. For the others the cause remains

unidentified and therefore unexplained; many in this group subsequently go on to achieve a pregnancy with specialist advice and

not requiring sophisticated treatment.

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PATIENT IDENTIFICATION PAGEComplete this page only if you are planning on having IVF/ ICSI/ IUI or Egg Donation treatment

FEMALE

Surname Ethnic Group

First Names Religion

Date of Birth *NHS No.

Town & Country of Birth

Names at Birth (if different from above)

Tel Nos: (Home) (Work)

Mobile Email

PARTNER

Surname Ethnic Group

First Names Religion

Date of Birth *NHS No.

Town & Country of Birth

Names at Birth (if different from above)

Tel Nos: (Home) (Work)

Mobile Email

Address

Postcode

It is helpful for us to know your new NHS Number for the processing of Laboratory Tests.

This may be found on your Medical Card or your GP’s secretary will be able to provide this information from your Medical Records.

PLEASE ATTACHPHOTO HERE

Please print nameand date of birthon back of photo

PLEASE ATTACHPHOTO HERE

Please print nameand date of birthon back of photo

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NOTES

Patient Self-History questionnaireBristol Centre for Reproductive MedicineSouthmead Hospital, Westbury-on-Trym, Bristol, BS10 5NBt: 0117 4146888 | f: 0117 4146899 | w: www.info@bcrm.org.uk

BCRM - 03.18