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Bangholm Medical Centre

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Annual Birthday Reviews
Mental Health Resources
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Practice Forms
Prescription Requests
Appointments
Vaccination Information
Our Services
Health Advice
A-Z of Community Resources
Become A Patient

Home
Language
Home
Meet The Team
Our Services
Health Advice
A-Z of Community Resources
Appointment Reminders
Contact Us

Fertility questionnaire form - Female

Last Updated: 29/10/2023

Female questionnaire

Please complete this questionnaire and ensure to book an appointment with one of our GP's to discuss the results.

Full Name *

Date of Birth *

Height (cm) *

Weight *

Blood Pressure (ie 130/80) *

How long have you been trying to conceive? *

Please give a brief description of your period cycle, giving details whether period is regular/irregular , cycle length, etc *

Please give any details of previous conception (including previous pregnancies, deliveries, miscarriages, abortions) *

Please give details of any previous history of assisted conception (IVF, IUI, Ovarian stimulation) *

Please give details of smoking /vaping status *

Heavy Smoker (+20 a day)

Moderate smoker (10-20 a day)

Light smoker (0-10 a day)

Vaper

ex-smoker

non-smoker

Please give details of drinking habits *

Heavy drinker ( over 30 units a week )

Moderate Drinker ( 15-30 units a week )

Light Drinker ( 0-15 units a week )

non-drinker

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