Female mandatory questionnaire

Gender(Required)

Please enter the gender you describe yourself as

Pronouns(Required)

Please enter the pronouns you prefer e.g. she/her, they/them

If you need an interpreter, which language?(Required)

Where were you born?(Required)

When did you move to the UK?(Required)

What is your job?(Required)

How long have you been in your current relationship?

Please tell us the number of years

How long have you been trying for a pregnancy?(Required)

Please tell us the number of years and months

How old are you on the day you are completing this questionnaire?(Required)

Please enter your age

What is your weight?(Required)

Please enter your weight in Kg

What is your height?(Required)

Please enter your height in metres

Section B – Partner Details

Partner's first name(Required)

Partner's last name(Required)

Section C – Previous Pregnancies

How many times have you been pregnant?(Required)

Which years were they?(Required)

Were they with your current partner or a previous partner?(Required)

Were they natural pregnancies or following fertility treatment?(Required)

What was the outcome of your pregnancies?(Required)

Please enter your pregnancy outcomes e.g. child born, miscarriage, termination

Did you have any problems in your pregnancy?(Required)

For example. diabetes, high blood pressure, bleeding, early delivery. Please provide details

Section D – Gynaecology History

Contraception details(Required)

How many days do you bleed for?(Required)

How frequently do you have a period?(Required)

This may be a range.

When was your last smear test(Required)

Further details(Required)

How frequently do you have intercourse?(Required)

Please enter how often you have sex

Previous treatment details(Required)

Section E – Medical and Surgical History

Further details about your condition(s)(Required)

Operation details(Required)

Please provide details of surgery and when you had the operation

Section F – Vaccination History

Further details(Required)

Section G – Medications History

Medication allergy details(Required)

Section H – Family History

Family history details

Please provide details of any conditions marked ‘Yes’

How many do you smoke per day?

How many units of alcohol do you drink in a week?(Required)

1 standard glass of wine = 1 unit 1 bottle of wine = 10 units 1 pint lager/beer/cider (normal strength) = 2 units 1 shot of a spirit = 1 unit

How many hours of exercise do you do in a week?(Required)

Please complete the following consent details.

Section A – Patient Details

Section B – Partner Details

Section C – Previous Pregnancies

Section D – Gynaecology History

Section E – Medical and Surgical History

Section F – Vaccination History

Section G – Medications History

Section H – Family History

Telephone

Support our charity

Cookie settings

Section A – Patient Details

Section B – Partner Details

Section C – Previous Pregnancies

Section D – Gynaecology History

Section E – Medical and Surgical History

Section F – Vaccination History

Section G – Medications History

Section H – Family History

Section I – Social History

Section J – Consent