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Boost Your Fertility Naturally...

Welcome and thank you for joining my program. I am confident that together we can work towards improving your fertility and achieving optimal pre conceptive health. You will improve your chances of falling pregnant naturally and carrying a healthy baby to term. If you are considering assisted reproduction techniques (IVF, IUI, ART), you will be giving yourself the best chance of success.

Now get comfortable and work through the following questionnaire, remembering to answer each question as honestly as you can. Make sure you answer EVERY question, including questions repeated in different sections. The more truthful your answers, the better we can tailor your program for you. This is not the time to be shy!

If you need to contact us, please feel free to call my clinic on 1300 133 536

Section 1 Personal Information

You may be asked to repeat some questions in different sections of the questionaire. Please answer each question again where prompted so we may accurately track your Fertility Assessment responses.

Please note: Fields marked with a * must be completed

		* First Name	* Surname

		* Email
		* Daytime Phone	* please include your area code
		Mobile Phone
		* Country
		* Age
		* Your height	centimeters (or) inches (5' = 60")
		* Your weight	kilograms (or) pounds (14lbs = 1 stone)
		* To assist with our marketing, please choose the source that led you to find our website:

Section 2

Sub Section 2a
What is your occupation? Please note:
Are you taking or using any prescriptive medications? *		Yes No
If yes, please list here:

Are you taking any over the counter medications? *		Yes No
If yes, list them here

Are you taking any natural remedies? *		Yes No
If yes, list them here


Sub Section 2b
Do you consume caffeinated beverages(coffee, soda, tea)?		Yes No
If yes, how many cups do you drink per day?
0 1 2-3 4 or more
Do you drink alcohol?		Yes No
If yes, how many standard alcoholic drinks per week?
1-3 4-6 7-10 11 or more
Do you smoke?		Yes No
If yes, how many packs of cigarettes a week?
less than 1 1 2-3 4 or more
Do you feel that you are underweight?		Yes No
If yes, please indicate by how many kilograms?
1-2 kgs 3-5 kgs 6+ kgs
Do you feel that you are overweight?		Yes No
If yes, how many kilos would you like to lose?
1-5 kgs 6-12 kgs 13-19 kgs 20-30 kgs 30+ kgs
Have any members of your immediate family suffered from weight gain?		Yes No
Have you ever had a drug addiction?		Yes No
Have you taken/used any recreational drugs in the past 12 months?		Yes No

Sub Section 2c
Have you had any recent surgery? *		Yes No
If yes, how long ago was the surgery?
1-3 months 5-12 months 1 year plus
If yes, please indicate the type of surgery
Gall bladder removal	Thyroid removal	Cyst or fibroid removal
Tumour removal
Other Surgery (please list)

Have you ever suffered from cancer? *		Yes No
If yes please indicate what type of cancer?
Breast Cancer	Cervical Cancer	Lymphatic
Endometrial	Brain	Bowel
Thyroid
Other Cancer (please list)

If yes, please indicate cancer treatment received
Surgical Removal	Radiotherapy	Chemotherapy
Other Cancer Treatment (please list)

If yes, how long ago was the cancer diagnosis?
0-6 months 7-12 months 1 year plus
If yes, how long ago was your last cancer treatment?
0-6 months 7-12 months 1 year plus
If yes, are you taking any medications for continued treatment? (please list in section 2a)		Yes No
Do you have Type 1 Diabetes? *		Yes No
Do you have Type 2 Diabetes? *		Yes No
If yes, are you taking any medications for Diabetes? (please list in Section 2a)		Yes No

Section 3

Sub Section 3a
Generally, do you feel? (tick applicable boxes)
Challenged	Demotivated	Depressed
Fearful of food	You have a low libido	Depleted
Alienated	Discouraged	Anxious
Out of control	Overwhelmed	Unattractive
Apathetic	Fearful	Angry
Do you feel you need to? (tick if applicable)
Forgive and forget	Move forward	Make changes in your life

Sub Section 3b
If weight gain is a problem for you - did you gain weight after? (tick if applicable)
A previous Pregnancy	Marriage	Divorce
Giving up smoking	Giving up sport	Major life trauma

Sub Section 3c
If weight gain is a problem for you - do you participate in the following behaviours in an attempt to lose weight? (please tick below where applicable)
Exercise excessively	Vomit	Use chemical laxatives
Avoid eating	Use natural laxatives e.g. bran, prunes, herbs

Section 4

Sub Section 4a
Do you experience? (tick where applicable)
Salt cravings	Rapid mood swings
Feel irritable or over sensitive	Foggy thinking or poor concentration
Feel exhausted or daunted	Feel like crying for no reason
An irritable or hyperactive bowel	Need coffee, tea, sugar, tobacco or other stimulants to get through the day
Work shift work or long hours	Difficulty sleeping
Fatigue, especially in the mornings	Lowered immune system (always getting sick)
Rapid heart beat	Dizziness and or fainting
Low blood pressure	Excessive perspiration
Anxiety attacks	Long term use of anti inflammatory drugs or cortisone
A trauma two or more years ago?	Extreme physical exercise
Drug or alcohol abuse	A recent trauma in the past two years?
Does life sometimes overwhelm you?		Yes No
Do you worry excessively?		Yes No
Are you a perfectionist?		Yes No
Do you consider yourself highly strung?		Yes No

Sub Section 4b
Do you suffer from Hypertension (high blood pressure)? *		Yes No Don't Know
Do you suffer from Hypotension (low blood pressure)? *		Yes No Don't Know
Do you have high Cholesterol? *		Yes No Don't Know
Do you suffer from Ulcers eg gastric/duodenal?		Yes No Don't Know
Do you suffer from Anaemia?		Yes No Don't Know
Do you suffer from Hypothyroidism (under active thyroid)?		Yes No Don't Know
Do you suffer from Hyperthyroidism (over active thyroid) ?		Yes No Don't Know
Do you suffer from Hashimoto's Disease?		Yes No Don't Know
Do you suffer from Grave's Disease?		Yes No Don't Know

Sub Section 4c
Are you being affected by? (please tick where applicable)
Continuous fatigue	Cold hands and feet
Times of depression	Muscles cramp and tremble
Lumpy breasts	Weight gain generally
Continuous, stubborn weight gain	Intolerance to cold
Dry skin	Heavy periods

Sub Section 4d
Do you suffer from Fibromyalgia		Yes No Don't Know
Have you had Glandular Fever or Epstein Barr Virus?		Yes No Don't Know
Do you suffer from auto immune disturbances?		Yes No Don't Know

Are you experiencing? (tick below if yes)
Aching muscles	Joint pain
Tightness in your throat	Debilitating fatigue

Sub Section 4e
Do you have any other chronic illness or medical condition? *		Yes No
If yes please list these

Do you currently have a sexually transmitted disease(STD)?		Yes No
If your answer is yes, please list type

Have you had a sexually transmitted disease (STD) in the past?		Yes No
If yes, please list type of STD

Section 5

Sub Section 5a
If you are overweight, were you overweight as a child?		Yes No
If yes, at what age did you begin struggling with your weight?
5-10yrs 11-15yrs 16-22yrs 23-30yrs 31-40yrs 41yrs plus
If yes, where are your weight problem areas? (Tick below where applicable)
Arms	Breasts	Neck
Waist	Hips	Bottom
Thighs	Calves	All Over

Sub Section 5b
Do You? (please tick those applicable)
Become tired mid afternoon	Have a tendency to accumulate fat around the waist
Become hungry mid afternoon	Snack at night
Eat high fat foods	Snack on sweets and sugary foods
Eat bread, pasta and rice	Crave carbohydrates e.g. pasta, rice, bread, fruit
Eat when you are not hungry	Feel drowsy after eating
Awake from sleep around 3am	Lack concentration
Experience excessive hunger

Section 6

Please tick those below you experience?
Intolerance to fatty foods	Indigestion, heartburn or reflux following a meal
High cholesterol	Difficult or irregular bowel movements
Abdominal bloating	Allergies
Skin rashes	Have offensive body odour
Vaginal Candida	Sores in the corners of your mouth
Digestive problems	Vaginal infections or itching
Tinea

Section 7

Sub Section 7a
How soon would you like to conceive?
3 months 6 months 12 months 18-24 months later
Have you ever conceived in the past?		Yes No
Have you ever given birth prematurely?		Yes No
Have you ever given birth full term?		Yes No
If yes, was it a lengthy complicated birth?		Yes No
Did you haemorrhage (lose a lot of blood) during labour?		Yes No
Have you ever had to have a cesarian birth?		Yes No
Have you ever had a miscarriage?		Yes No
If yes, how many times have you miscarried?
1 2 3 3 or more
Have you ever terminated a pregnancy?		Yes No
If yes, how many times have you terminated a pregnancy?
1 2 3 or more
How long have you been actively trying to conceive?
Not trying yet 0-3 months 4-12 months 1 year plus
Are you currently on IVF treatment?		Yes No
Have you attempted IVF treatment in the past?		Yes No
Are you currently taking any medications for IVF treatment?(if so, please list in question 2a)		Yes No
Are you taking any other prescription medications to enhance fertility?(if so, please list in question 2a)		Yes No
Do you have a blockage in the fallopian tubes?		Yes No
Have you had previous infections in the fallopian tubes?		Yes No
Have you ever had an ectopic pregnancy?		Yes No
Do you have any abnormalities of the uterus?		Yes No
Have any other members of your family had problems with genetic defects or still births?		Yes No
Are you a DES daughter? (did your mother take diethylstilbestrol, a synthetic oestrogen given to women between 1941 and 1971 to prevent miscarriage)		Yes No
Are you currently breastfeeding? *	Yes No about to finish
If yes, how old is the child you are breastfeeding?
0-3 months 4-6 months 7-12 months 12 months plus

Sub Section 7b
Do you currently use an intrauterine device (IUD)? (If yes please list in section 2a)		Yes No
Do you currently take an oral contraceptive pill? (If yes please list in section 2a)		Yes No
Do you currently take or use prescriptive contraceptives e.g. implant,injection? (If yes please list in section 2a)		Yes No
If yes to any of the above, when do you plan to cease its use and begin planning conception?
less than 1 month 1-3 months 3 months plus
If you have used prescriptive contraception in the past, how long ago did you cease using it?
less than 1 month 1-3 months 3-6 months 6 months plus

Sub Section 7c
At what age did you get your first menstrual bleed?
under 10 11-13 years 14-16 years 17-19 years 20 years+
Do you experience a menstrual bleeding (periods)? (If yes please list in section 2a)		Yes No
If so, how long is your menstrual cycle?
20 days or less 21-27 days 28-32 days 33 days plus
If so, how many days does your period last for?
2 days or less 3-4 days 4-6 days 7 days plus
Have you been experiencing?
An irregular menstrual cycle. For example, cycle lengths that vary greatly?		Yes No
Are your periods generally more than 45 to 50 days apart?		Yes No
Are your periods generally less than 20 days apart?		Yes No
Are your periods generally exceptionally light?		Yes No
Do you generally experience periods that are very heavy?		Yes No
Are your periods so heavy that they interfere with your lifestyle or regular activities?		Yes No
Do you spot between periods or have any unexplained bleeding?		Yes No
Are you passing large clots?		Yes No
Do you feel weak or dizzy during your period?		Yes No
During menstruation, do you have mild to moderate pelvic pain or cramping?		Yes No
During menstruation, do you have severe or debilitating pelvic pain or cramping?		Yes No
Are you experiencing Peri menopause (the start of Menopause)?		Yes No Don't Know

Sub Section 7d
Do you suffer from Premenstrual Syndrome?		Yes No
Do you experience the following symptoms Pre Menstrually? (pls tick those applicable)
Pain or Cramping	Headaches or Migraines	Fatigue
Tender or swollen breasts	Bloating or fluid retention	Mood swings
Depression	Poor sleep patterns	Anxiety
Sugar cravings	Increased appetite

Sub Section 7e
Do you ovulate? *		Yes No Don't Know
How often do you ovulate?
Monthly Irregularly Don't Know
How long is the duration of your ovulation?
1-2 days 3 days or more Don't Know
Do you experience pain on ovulation?		Yes No
Do you experience mucus secretions upon ovulation?		Yes No

Sub Section 7f
Have you been diagnosed with Endometriosis? *		Yes No
Do you experience? (tick those applicable)
Pelvic pain	Pain before and or after menstruation
Severe menstrual cramps	Painful intercourse or orgasms
Lower back pain	Bladder pain and or frequency of urination
Fatigue	Heavy or irregular menstrual bleeding
Intestinal distress such as bloating, vomiting, nausea	Painful bowel movements often with cycles of diarrhoea and constipation

Sub Section 7g
Have you been diagnosed with Polycystic Ovarian Syndrome? (PCOS) *		Yes No
Do you experience? (Tick those applicable below)
Irregular or absent periods	Acne
Excessive or unwanted hair growth	Male patterned balding	Excessive weight gain

Sub Section 7h
Have you been diagnosed with Ovarian Cysts? *		Yes No
Tick any symptoms you are experiencing?
Feeling of pressure on your bladder or rectum	A fullness or heaviness in your abdomen
Nausea or breast tenderness similar to if you were pregnant	Continuous, creamy or clear like (eggwhite) vaginal discharge that persists unchanged for a month or more
Pelvic pain during intercourse	Pelvic pain just before your period begins or just after it ends
Pelvic pain. A dull ache, either constant or intermittent, possibly radiating to the low back or thighs

Sub Section 7i
Have you been diagnosed with Fibroids? *		Yes No
Tick the below symptoms you experience
Heavy periods	Discomfort in your lower abdomen (tummy)
Anaemia	Need to pass urine more often than normal
Constipation	Pain or discomfort during sexual intercourse (Dyspareunia)
Severe pain	Difficulty conceiving

Additional information or clarification

Please write briefy and to the point

If you have any recent blood tests please fax them to (03) 9852 9933 or email to testresults@bumpfertility.com.au

Submit your Questionnaire

To proceed with payment click the submit button.

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