Reproductive History for Fertility and Menopause

Reproductive Health Questionnaire - please complete at least 48 hours before your first appointment. If you have any problems completing the form please contact bridgnorthholistictherapies@gmail.com.

All information is held in strictest confidence, and will not be disclosed or shared without obtaining your written consent. The questions here are of a personal nature and will enable me to develop the most appropriate fertility or menopause treatment plan; if there is anything you would feel more comfortable discussing in person or at a later date rather than writing down now, please note this in the form.

Menopause/perimenopause clients please complete sections 1, 2 and 3 in full. Fertility clients please complete sections 1, 2 and 4 in full.
Name*

First NameLast Name
Email*
Section 1: Lifestyle Questionnaire
Please give details of your height, weight and BMI (if known):
Is anything at present causing you to feel anxious or stressed? Please give details here:
What are your current exercise levels?

None/sedentary lifestyleExercise 1-2 times per weekExercise 3 or more times per week
Do you drink alcohol?

NoYes
If you drink alcohol, how many units per week on average?
Do you smoke?

NoYes
If you smoke, how many cigarettes per day on average?
Please describe your sleep patterns (e.g. quality, quantity, any regular waking periods)*
How many times have you been pregnant?
Please give birth details where applicable (e.g. how long ago, method of delivery, any complications)
GP details:
Section 2: Menstrual Cycle

If you have reached menopause, please skip this section.
What is the length of your cycle (days)?
Does your cycle length vary?

No, always the same amount of daysYes, but only by 1-2 daysYes, by 3-7 daysIt is unpredictable and varies by more than 7 days
Please give dates and length of your last three menstrual cycles (if known):
Do you experience any of the following physical PMS symptoms?

BloatingConstipation/wind/diarrhoeaSore or tender breastsCrampingFood cravingsHot flushes or night sweatsSleep disturbancesTiredness or lethargyJoint or muscle aches/painsHeadaches
Do you experience any of the following emotional PMS symptoms?

DepressionTearfulnessAngerIrritabilityMood swingsConfusion/forgetfulnessPoor concentrationChanges in libidoAnxiety
If you have ticked any of the physical or emotional PMS symptoms above, please give further details (e.g. how long it lasts, any treatment, what helps, what makes things worse)
Have you suffered from any of the following gynaecological issues?

AmenhorrhoeaAnovulationPainful periodsOvulation painMalformed wombOvarian cystsAdenomyosisEndometriosisFallopian tube issuesThrushGenital ulcersLow back painCystitisPain on intercourseVaginal discharge/burning/irritationWater retentionFibroids
If you have ticked any of the gynaecological issues above, please give further details (e.g. when suffered, any treatment, current status)
Have you used any of the following methods of contraception?

CoilDiaphragmContraceptive pillContraceptive injectionCondomNatural family planningSpongeOther
Current method of contraception and length of time used:
Section 3: Menopause Clients Only
Date of last period:
Do any of the following apply?

Diagnosed premature menopause/POI/POFMedical menopause (e.g. caused by chemotherapy/radiotherapy)Surgical menopause (e.g. removal of ovaries or uterus)Medically diagnosed/GP confirmed menopauseMedically diagnosed/GP confirmed perimenopauseTaking Hormone Replacement Therapy/other medication
Please give further details if you have ticked any of the above (e.g. dates/medical procedures/tests)
Please tick all of the menopause symptoms you have experienced:

Hot flushes/flashesNight sweatsInsomnia or difficulty sleepingForgetfulnessMood changesDecreased interest in sexJoint stiffnessAnxietyWeight gainSkin/hair/nail changesDigestive issuesHeart racing or pounding/palpitationsDizzinessHeadachesFatigueVaginal drynessUrine leakage
Which of the above symptoms do you find the most difficult to cope with? Please note how often they occur, any treatments or medication, and anything else you have tried to ease the symptoms
Section 4: Fertility Clients Only
How long have you been trying to conceive?
Are you aware of when in your cycle ovulation takes place?
Are you tracking your cycles using a chart/BBT?
Fertility clinic and consultant (if applicable):
Have you/your partner had any of the following?

STI testingSemen analysisFemale blood hormone profile (FSH/LH/Oestrogen/Prolactin)Progesterone blood test (day 21/7DPO)Thyroid function blood testAnaemia blood testTransvaginal scanHSG/HyCoSyLaporoscopyHysteroscopyEndometrial biopsyOvarian reserve/AMH testingOther investigations
Please provide any test results/outcome of any investigations (if you'd like to upload any copies please attach underneath):
Please upload any copies of test results or anything else you would like to share here:

Browse Files

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Have you had any previous fertility treatments?

IUIIVFICSIMedicated cycles (e.g. Clomid)
Please give full details of any previous treatments:
Is there any other information about current or previous fertility issues you would like to share?
Client Declaration:

I have completed the above questionnaire fully and declare the information I have given is complete and true, and as far as I am aware I can undertake massage, reflexology or Gentle Release Therapy with Bridgnorth Holistic Therapies without adverse effects. Any potential contra-indications highlighted by the medical questionnaire above will be discussed at the time of my appointment. I understand that massage, reflexology and Gentle Release techniques are not substitutes for medical examination, diagnosis or treatment. I give my informed consent to proceed.
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