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Sexual Assault – SATU
Rotunda Semi-Private & Private
Home
Visitor Information
Hampson House
About Rotunda
Meet Your Team
FAQ’s
Planning a Baby
Ovulation Calculator
Rotunda Fertility Hub
Pregnancy
Due Date Calculator
First Antenatal Visit
Maternity Care Options
Healthy Pregnancy
Crisis Pregnancy
Problems and Concerns
Monochorionic Multiple Birth Service
Birth
Hospital Bag
Labour & Birth
Assisted Delivery
Post Natal Care
Baby Care
Caring For Baby
Feeding Baby
Neonatal Unit
Paediatric Outpatients
Women’s Health
Gynaecology
Colposcopy
Menopause Clinic
Admission Preparation
Support
Breastfeeding Support
Parent Education
Specialist Clinics
Nutrition and Dietetics
Physiotherapy
Mental Health
Advice for Partners
Bereavement
Miscarriage
Sexual Assault – SATU
Rotunda Semi-Private & Private
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Click here to download the HSE Regional Fertility Hub Information Booklet
HSE Patient History Assessment Form
Male Fertility Screening Questionnaire
1. Personal Details
First Name
Last Name
Address
Date of Birth
Phone
Email Address
Height in cm
Weight in kg
2. Relationship Status
Are you
Single
In a relationship
If you are in a relationship, please complete below as appropriate
Relationship
Heterosexual
Same Sex
Other
Length of relationship in Years and Months
Please state your partner’s name
Please state your partner’s date of birth
3. Previous pregnancies
Have you ever had a pregnancy with any partner?
Yes
No
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?
Yes
No
If yes, was your child/children adopted with your current partner?
Yes
No
4. Previous fertility treatment
Have you ever had previous fertility investigations, e.g. semen analysis?
Yes
No
If yes, please give details
Investigation
Result
Year
Fertility Service Provider
Have you ever had fertility treatment?
Yes
No
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?
Yes
No
Have you ever had IVF / ICSI?
Yes
No
Do you have any stored material remaining, e.g. embryos, eggs or sperm in storage?
Yes
No
5. Sexual history
Have you any difficulties with?
Erections
Yes
No
Ejaculation (release of sperm from your penis)
Yes
No
Sex/Intercourse
Yes
No
If yes, please provide details
Have you ever had a sexually transmitted infection (STI)?
Yes
No
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;
Hepatitis
Yes
No
If yes please indicate result;
HIV
Yes
No
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?
Yes
No
If yes, how many per day?
Do you vape?
Yes
No
Do you currently use recreational drugs?
Yes
No
Do you drink alcohol?
Yes
No
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
*
Yes, I agree with the
privacy policy
.
Submit
HSE Patient History Assessment Form
Fem
ale Fertility Screening Questionnaire
1. Personal Details
First Name
Last Name
Address
Date of Birth
Phone
Email Address
Height in cm
Weight in kg
2. Relationship Status
Are you
Single
In a relationship
If you are in a relationship, please complete below as appropriate
Relationship
Heterosexual
Same sex
Other
Length of relationship in Years and Months
Please state your partner’s name
Please state your partner’s 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
4. Menstrual history
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?
Yes
No
Do you know when you ovulate?
Yes
No
If yes; i) How do you know? i.e. test kit, pain, discharge
Around what day during your cycle do you ovulate?
5. Gynaecological history
Have you ever had any gynaecological issues? Please tick yes as appropriate
If yes; provide details
Ovarian cysts
Yes
No
Endometriosis
Yes
No
If yes; provide details
PCOS (Polycystic ovarian syndrome)
Yes
No
If yes; provide details
Pelvic infection
Yes
No
If yes; provide details
Polyp
Yes
No
If yes; provide details
Fibroids
Yes
No
If yes; provide details
Cervical smear that needed treatment, e.g. Lletz, cone biopsy, laser
Yes
No
If yes; provide details
Treatment for cancer
Yes
No
If yes; provide details
Any other conditions that may be relevant
6. Previous pregnancies
Have you ever been pregnant before? If yes, please provide details below
Yes
No
Livebirths
Date of birth
Number of weeks pregnant at delivery
Type of Delivery (caesarean or vaginal)
Conceived with current partner
Stillbirths
Date of birth
Number of weeks pregnant at delivery
Type of Delivery (caesarean or vaginal)
Conceived with current partner
Miscarriages
Month
Year
Number of weeks pregnant
Conceived with current partner
Termination of pregnancy
Month
Year
Number of weeks pregnant
Conceived with current partner
Ectopic Pregnancy
Month
Year
Number of weeks pregnant
Conceived with current partner
Did you experience any pregnancy related complications? If yes, please complete as appropriate
Have you previously had bloods taken for;
Gestational diabetes
Yes
No
Pre-eclampsia
Yes
No
Post-partum haemorrhage
Yes
No
Preterm delivery
Yes
No
Other
Do you have any adopted children?
Yes
No
If yes, was your child/children adopted with your current partner?
Yes
No
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?
Yes
No
Had previous fertility investigations?
Yes
No
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?
Yes
No
Have you ever had IVF / ICSI?
Yes
No
Do you have any stored material remaining, e.g. embryos, eggs or sperm in storage?
Yes
No
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 sex
Yes
No
If yes please provide details;
Have you ever had a sexually transmitted infection (STI)?
Yes
No
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;
Hepatitis
Yes
No
If yes please indicate result;
HIV
Yes
No
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?
Yes
No
If yes, how many per day?
Do you vape?
Yes
No
Do you currently use recreational drugs?
Yes
No
Do you drink alcohol?
Yes
No
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
*
Yes, I agree with the
privacy policy
.
Submit
Search
HSE Patient History Assessment Form Female Fertility Screening Questionnaire