Women's Health

Fertility Form

Click here to download the HSE Regional Fertility Hub Information Booklet

HSE Patient History Assessment Form Male Fertility Screening Questionnaire

1. Personal Data

NAME

ADDRESS

DATE OF BIRTH

PHONE

EMAIL ADDRESS

HEIGHT IN CM

WEIGHT IN KG

2. Relationship Status

Are youSingleIn a relationship

If you are in a relationship, please complete below as appropriate

RelationshipHeterosexualSame sexOther

Length of relationship in Years and Months

Please state your partner's date of birth

3. Previous Pregnancies

Have you ever had a pregnancy with any partner?YesNo

Please state your partner's name

Have you ever had a pregnancy with any partner?YesNo

If yes, please provide details of these pregnancies below, other than those that may have been achieved with your current partner (Details of these pregnancies will have been provided by your partner in her questionnaire)

Livebirth (total number and years)

Miscarriage (total number and years)

Ectopic pregnancy (total number and years)

Termination of pregnancy (total number and years)

Stillbirth (total number and years)

Do you have any adopted children?

If yes, was your child/children adopted with your current partner?

4. Previous fertility treatment

Have you ever had previous fertility investigations e.g semen analysis?YesNo

If yes, please give details

Investigation

Result

Year

Fertility service provider

Have you ever had fertility treatment?YesNo

If yes, please provide details of this treatment below, other than treatment with your current partner (details of these treatments will have been provided by your partner in her questionnaire)

Have you ever had fertility treatment involving IUI?YesNo

Have you ever had IVF / ICSI?YesNo

Do you have any stored material remaining, e.g. embryos, eggs or sperm in storage?YesNo

5. Sexual History

Have you any difficulties with?

ErectionsYesNo

Ejaculation (release of sperm from your penis)YesNo

Sex/IntercourseYesNo

If yes, please provide details

Have you ever had a sexually transmitted infection (STI)?YesNo

If yes; which infection and what treatment did you receive?

6. Medical / Surgical History

Please detail any significant medical conditions or treatment, e.g diabetes, heart disease, cancer treatment.

Please detail any surgeries or difficulties with your testicles, scrotum, penis or hernias. Please provide surgery dates

Have you previously had bloods taken for;

HepatitisYesNo

If yes please indicate result;

HIVYesNo

If yes please indicate result;

7. Current medications

Please list your current medications (inclusive of non-prescribed medication, e.g. vitamins, supplements)

8. Family history

Please provide details of any hereditary disorders, birth defects or fertility challenges in your family.

9. General health

Do you smoke?YesNo

If yes, how many per day?

Do you vape?YesNo

Do you currently use recreational drugs?YesNo

Do you drink alcohol?YesNo

If yes, how many standard drinks do you have on average every week? 1 standard drink = ½ pint of beer, 1 small glass of wine or 1 single measure of spirits

Any other information you think is relevant

Consent *

I consent to the collection and processing of my personal and health information in accordance with the General Data Protection Regulation (GDPR) and applicable data protection laws.

HSE Patient History Assessment Form Female Fertility Screening Questionnaire

1. Personal Details

Name

Street Address

Date of Birth

Telephone

Height in cm

Weight in Kg

2. Relationship Status

Are youSingleIn a relationship

If you are in a relationship, please complete below as appropriate

RelationshipHeterosexualSame sexOther

Length of relationship in Years and Months

Please state your partner’s name

Please state your date of birth

3. Fertility

When did you start trying to purposefully get pregnant, i.e. when did you commence having regular, unprotected vaginal intercourse?

Month

Year

On average how many days is your menstrual cycle, i.e. from the start of one period to the start of the next one?

Date of last period

Does your period affect your ability to undertake normal daily activities?YesNo

Do you know when you ovulate?YesNo

If yes; i) How do you know? i.e. test kit, pain, discharge

ii) Around what day during your cycle do you ovulate?

5. Gynaecological history

Have you ever had any gynaecological issues? Please tick yes as appropriate

Ovarian cystsYesNo

If yes, please provide details

EndometriosisYesNo

If yes, please provide details

PCOS (Polycystic Ovarian Syndrome)YesNo

If yes, please provide details

Pelvic InfectionYesNo

If yes, please provide details

PolypYesNo

If yes, please provide details

FibriodsYesNo

If yes, please provide details

Cervical smear that needed treatment, e.g. LLETZ, cone biopsy, laserYesNo

If yes, please provide details

Treatment for cancerYesNo

If yes, please provide details

Any other conditions that may be relevant

6. Previous pregnancies

Have you ever been pregnant before? If yes, please provide details belowYesNo

Livebirths

Date of Birth

Number of weeks pregnant at delivery

Type of delivery (caesarean or vaginal)

Conceived with current partnerYesNo

Date of Birth

Number of weeks pregnant at delivery

Type of delivery (caesarean or vaginal)

Conceived with current partnerYesNo

Date of Birth

Number of weeks pregnant at delivery

Type of delivery (caesarean or vaginal)

Conceived with current partnerYesNo

Stillbirths

Date of Birth

Number of weeks pregnant at delivery

Type of delivery (caesarean or vaginal)

Conceived with current partnerYesNo

Miscarriages

Month

Year

Number of weeks pregnant

Conceived with current partnerYesNo

Month

Year

Number of weeks pregnant

Conceived with current partnerYesNo

Month

Year

Number of weeks pregnant

Conceived with current partnerYesNo

Termination of pregnancy

Month

Year

Number of weeks pregnant

Conceived with current partnerYesNo

Ectopic Pregnancy

Month

Year

Number of weeks pregnant

Conceived with current partnerYesNo

Did you experience any pregnancy related complications? If yes, please complete as appropriate.

Gestational diabetesYesNo

Pre-eclampsiaYesNo

Post-partum haemorrhageYesNo

Preterm deliveryYesNo

Other

Do you have any adopted children?YesNo

If yes, was your child/children adopted with your current partner?YesNo

7. Previous fertility treatment

Other than your recent visit with your GP who initiated this referral, have you;

Seen a doctor before regarding your fertility?YesNo

Had previous fertility investigations?YesNo

If you ticked yes to previous fertility investigations, please complete table to the best of your availability?

Investigation

Result

Year

Fertility Service Provider

Have you ever had fertility treatment involving IUI?YesNo

Have you ever had IVF / ICSI?YesNo

Do you have any stored material remaining, e.g. embryos, eggs or sperm in storage?YesNo

Please note that if you have undergone private fertility treatment previously, i.e. IUI and/or IVF/ICSI, you will need to seek a discharge summary of your care from the relevant private provider. This will ensure that the fertility team in the regional service have a complete record of all your previous medical treatment in this area of care. You will need to bring this discharge summary to your first appointment in the regional service.

8. Sexual history

Have you ever had problems with sexual intercourse or vaginal examinations, e.g. pain, high levels of discomfort, dryness, unable to have vaginal sexYesNo

If yes please provide details;

Have you ever had a sexually transmitted infection (STI)?YesNo

If yes; which infection and what treatment did you receive?

9. Current medications

Please list your current medications (inclusive of non-prescribed medication, e.g. vitamins, folic acid)

10. General medical / surgical history

Please detail any significant medical conditions, e.g. asthma, diabetes, inflammatory bowel disease, cancer treatment.

Please detail any previous general surgery, e.g. appendicitis, bowel surgery. Please provide the surgery dates.

Have you previously had bloods taken for HepatitisYesNo

If yes please indicate result;

Have you previously had bloods taken for HIVYesNo

If yes please indicate result;

11. Family history

Please provide details of any hereditary disorders, birth defects or fertility challenges in your family

12. General health

Do you smoke?YesNo

If yes, how many per day?

Do you vape?YesNo

Do you currently use recreational drugs?YesNo

Do you drink alcohol?YesNo

If yes, how many standard drinks do you have on average every week? 1 standard drink = ½ pint of beer, 1 small glass of wine or 1 single measure of spirits

13. Any other information you think is relevant

Consent *

I consent to the collection and processing of my personal and health information in accordance with the General Data Protection Regulation (GDPR) and applicable data protection laws.

Fertility Form

Click here to download the HSE Regional Fertility Hub Information Booklet

HSE Patient History Assessment Form Male Fertility Screening Questionnaire

1. Personal Data

2. Relationship Status

If you are in a relationship, please complete below as appropriate

3. Previous Pregnancies

If yes, please provide details of these pregnancies below, other than those that may have been achieved with your current partner (Details of these pregnancies will have been provided by your partner in her questionnaire)

4. Previous fertility treatment

If yes, please give details

5. Sexual History

Have you any difficulties with?

6. Medical / Surgical History

Have you previously had bloods taken for;

7. Current medications

8. Family history

9. General health

HSE Patient History Assessment Form Female Fertility Screening Questionnaire

1. Personal Details

2. Relationship Status

If you are in a relationship, please complete below as appropriate

3. Fertility

When did you start trying to purposefully get pregnant, i.e. when did you commence having regular, unprotected vaginal intercourse?

5. Gynaecological history

Have you ever had any gynaecological issues? Please tick yes as appropriate

6. Previous pregnancies

Livebirths

Stillbirths

Miscarriages

Termination of pregnancy

Ectopic Pregnancy

Did you experience any pregnancy related complications? If yes, please complete as appropriate.

7. Previous fertility treatment

Other than your recent visit with your GP who initiated this referral, have you;

If you ticked yes to previous fertility investigations, please complete table to the best of your availability?

8. Sexual history

9. Current medications

10. General medical / surgical history

11. Family history

12. General health

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