(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)
Were there any issues with pregnancy?
(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)
Are you an Egg Donor?
(Required)
Yes
No
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
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?
Are you an ex-smoker?
(Required)
Yes
No
How many per day?
If yes, when did you quit
Do you consume alcohol on a regular basis?
(Required)
Yes
No
If yes, how many standard drinks per week?
How frequently would you have more than 4 drinks in one setting?
(Required)
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
Do you have a family history of genetic disorders or birth defects?
(Required)
Yes
No
Please provide details
Do you have a family history of chronic medical conditions?
(Required)
Yes
No
Please provide details
(Required)
Would you like reproductive carrier screening included in your workup?
(Required)
Yes
No
Unsure
If Yes, which option?
(Required)
Government-funded panel
Expanded carrier screening
Are you overdue for your Cervical Screening Test (CST)?
(Required)
Yes
No
Unsure
If Yes, would you like to do a self-collected CST at your visit?
(Required)
Yes
No
Are you interested in PGT?
(Required)
Yes
No
Unsure
Are you interested in donor?
(Required)
Yes
No
Unsure
BMI over 35
(Required)
Yes
No
Are you using St John of Wort supplement?
(Required)
Yes
No
Any history of blood clots, DVT, PE, or clotting disorders?
(Required)
Yes
No
Do you have hypertension, migraines (with aura), or liver disease?
(Required)
Yes
No
History of breast cancer or hormone-sensitive cancers?
(Required)
Yes
No
Are you currently breastfeeding?
(Required)
Yes
No
Additional Information
Please feel free to provide any other relevant information or concerns regarding your fertility and overall health:
Emergency contact Name
Emergency contact Relationship
Emergency contact Mobile
Emergency contact Address
Emergency contact Postcode
Emergency contact Email
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