(08) 6289 3838
admin@oasisfertilitycentre.com.au
About
Our Team
Services
Fertility Services
Free Fertility Assessment
Donor Program
Donor Program
Egg Donors
Embryo Donors
Sperm Donors
Recipients
Laboratory Services
Service Enquiry
Costs
Success Rate
Resources
Patient Resources
GP Resources
Common Questions
Wellness Centre
Diet & Nutrition
Naturopathy
Acupuncture
Stress & Fertility
Counselling & Psychology
Sound Healing
Make A Booking
MAKE A BOOKING
About
Our Team
Services
Fertility Services
Free Fertility Assessment
Donor Program
Donor Program
Egg Donors
Embryo Donors
Sperm Donors
Recipients
Laboratory Services
Service Enquiry
Costs
Success Rate
Resources
Patient Resources
GP Resources
Common Questions
Wellness Centre
Diet & Nutrition
Naturopathy
Acupuncture
Stress & Fertility
Counselling & Psychology
Sound Healing
Health Questionnaire for Females
First Name
(Required)
Last Name
(Required)
Are you currently trying to conceive?
(Required)
Yes
No
How long have you been trying to conceive?
(Required)
Have you been pregnant before?
(Required)
Yes
No
How many times?
(Required)
How many live births?
(Required)
Do you have any known fertility issues?
(Required)
Yes
No
Please provide details
(Required)
Have you ever had any previous gynaecological surgeries?
(Required)
Yes
No
Please provide details
(Required)
Medical History
Have you been diagnosed with ay chronic medical conditions? (e.g. diabetes, hypertension, thyroid disease)
(Required)
Yes
No
Please provide details:
(Required)
Are you currently taking any medications?
(Required)
Yes
No
Please list them
(Required)
Are you currently taking any supplements?
(Required)
Yes
No
Please list them
(Required)
Please list your current:
Height (cm)
(Required)
Weight (kg)
(Required)
BMI
(Required)
How would you describe your diet/ nutrition?
Lifestyle History
Are you a current smoker/vaper?
(Required)
Yes
No
If yes, how many/day
When did you start?
Do you consume alcohol on a regular basis?
(Required)
Yes
No
If yes, how many standard drinks per week?
What is your current occupation?
(Required)
Are you a FIFO worker
(Required)
Yes
No
Family History
Do you have a family history of fertility issues?
(Required)
Yes
No
Please provide details
(Required)
Do you have a family history of genetic disorders or birth defects?
(Required)
Yes
No
Please provide details
(Required)
Do you have a family history of chronic medical conditions?
(Required)
Yes
No
Please provide details
(Required)
Additional Information
(Required)
Please feel free to provide any other relevant information or concerns regarding your fertility and overall health:
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