Health Questionnaire – Female – Oasis Fertility Centre: Perth, WA

Health Questionnaire - Female

First Name

Last Name

Are you currently trying to conceive?

Yes
No

How long have you been trying to conceive?

Have you been pregnant before?

Yes
No

Do you have any known fertility issues?

Yes
No

Have you ever had any previous gynaecological surgeries?

Yes
No

Are you an Egg Donor?

Yes
No

Medical History - Have you been diagnosed with any chronic medical conditions? (e.g. diabetes, hypertension, thyroid disease)

Yes
No

Please list your current and past medical conditions

If none please put N/A

Are you currently taking any medications?

Yes
No

Please list your current medications and supplements

If none please put N/A

Are you currently taking any supplements?

Yes
No

Please list your current: Height (cm)

Weight (kg)

BMI

How would you describe your diet/ nutrition?

Lifestyle History - Are you a current smoker/vaper?

Yes
No

Are you an ex-smoker?

Yes
No

Do you consume alcohol on a regular basis?

Yes
No

How frequently would you have more than 4 drinks in one setting?

How many drinks would you have in a typical week (if any)?

What is your current occupation?

Are you a FIFO worker

Yes
No

Family History - Do you have a family history of fertility issues?

Yes
No

Do you have a family history of genetic disorders or birth defects?

Yes
No

Do you have a family history of chronic medical conditions?

Yes
No

Would you like reproductive carrier screening included in your workup?

Yes
No
Unsure

Are you overdue for your Cervical Screening Test (CST)?

Yes
No
Unsure

If Yes, would you like to do a self-collected CST at your visit?

Yes
No

Are you interested in PGT?

Yes
No
Unsure

medical taking you

Are you interested in donor?

Yes
No
Unsure

BMI over 35

Yes
No

Are you using St John of Wort supplement?

Yes
No

Any history of blood clots, DVT, PE, or clotting disorders?

Yes
No

Do you have hypertension, migraines (with aura), or liver disease?

Yes
No

History of breast cancer or hormone-sensitive cancers?

Yes
No

Are you currently breastfeeding?

Yes
No

Additional Information

Emergency contact Name

Emergency contact Relationship

Emergency contact Mobile

Emergency contact Address

Emergency contact Postcode

Emergency contact Email

This is what better feels like.
CLEARER. CALMER. MORE HUMAN.

Health Questionnaire - Female

That's the Oasis difference.