Fertility Consultation Form

I appreciate you taking the time to complete the following consultation form as best you can. Each question will be discussed at your consultation to ensure that nothing is missed, but the more information you provide here, the better I can tailor your fertility consultation and subsequent treatment to your needs. 

Please complete and submit this form prior to your consultation.

Many thanks

Jade

 

 

Basic information
Today's Date
Today's Date
Name
Name
Date of Birth
Date of Birth
Address
Address
Would you like to subscribe to Meant to Bee Newsletters? *
I promise not to spam you! Only important information regarding appointment and news about the clinic will be sent -I wouldn't want you to miss out on special offers and discounts or closed dates. Tick which newsletters you would like to subscribe to
Preferred method of contact
Emergency contact
Emergency contact
Reason for visit
Does this condition interfere with
Medical History
Name of Practitioner
Name of Practitioner
Address of practitioner
Address of practitioner
General health conditions
Please check all that apply to you, including past and present conditions
Gastrointestinal History
Do you experience any of the following?
Family History
Please answer the following questions in relation to each family member - Are they still alive? If not, what was the cause of death? Did they have any major health issues?
Lifestyle, Emotional and Spiritual Information
Reproductive Health History
When did your last period begin? If unsure, choose an approximate date
When did your last period begin? If unsure, choose an approximate date
Reproductive conditions
Please check all that apply to you, including past conditions
History of Trauma
Please answer what you feel comfortable sharing. This work can release emotions and so it may be helpful for me to be aware of any issues
Fertility Information
If you feel comfortable sharing details here, and it's appropriate, please include how many eggs you had collected, how many eggs fertilised, how many embryos were transferred, and how many were frozen, did you reach your pregnancy test date, what was the outcome?
Pregnancy history
Which methods of delivery have you experienced? Please check all that apply
Have you experienced any of the following?
Has any members of your maternal family experienced any of the following
Please read and confirm
Your personal data will be stored and be accessible by Meant to Bee Therapies - Jade Adair Your information will not be shared to any third party companies. We will only contact you with regards to Meant to Bee Therapies and associated matters and will never send spam to you. Medical Malpractice: Your details will be kept on record for 3 years once you have recieved your last treatment with Jade Adair Record Keeping Your consultation forms are kept on file on a password protected computer and paper files are kept in a locked filing cabinet at my home address. Your files are not viewed or accessible by anyone other than Jade Adair, unless consent is given by yourself to share with other therapists. Medical Information Required The medical & emotional questions are required so that Jade Adair can provide a Holistic Treatment for you.