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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. On completion of this initial questionnaire, your payment is processed using Westpac's online payment facility. No credit card details are housed on my site. Once completed, I will call you with 2 working days to discuss your needs and commence formulation of your preconceptive health plan to make pregnancy possible!

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


Section 1 Personal Information
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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: 
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Section 2
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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
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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     
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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      
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Section 3
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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
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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
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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
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Section 4
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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      
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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
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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
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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
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Are you experiencing? (tick below if yes)
Aching muscles Joint pain
Tightness in your throat Debilitating fatigue
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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
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Section 5
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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
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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
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Section 6
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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
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Section 7
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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
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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
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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
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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
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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      
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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
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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
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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
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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
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Additional information or clarification
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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
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Submit your Questionnaire
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To proceed with payment click the submit button.