Glow Confidential Intake Form

PRIVATE and CONFIDENTIAL Client Information This form asks for some basic current details, but also goes into some quite personal, and maybe even some challenging information. If you do not want to answer all of these questions, or feel like it is too difficult to at this particular time, then that is absolutely fine. Please fill in what you can and return to me before your appointment if possible (or you’d rather just bring it with you on the day that is also fine). If any of these questions stir up any difficult emotions, please contact me in the meantime. Many thanks, Jay.

Personal Details
Name
First Last
Address
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
Phone
Email
Enter Email Confirm Email
Date of birth
Current age
Occupation (now or former)
Partners name
First Last
Marital status
How long have you been together?
Do you or your partner have any children or dependants?
- Yes
- No
What are their names and ages?
Medical or Other Practitioners
GP name and surgery
Fertility clinic and consultants name, if relevant
List any other therapists/therapies that you use
Current medication
Supplements or remedies that you are currently taking
Do you smoke? (How many? If stopped, when?)
Alcohol (How much?)
Have you ever had any kind of substance abuse/addiction?
Allergies (specific allergen and reaction)
Surgical history or recent procedures (year and type)
Accidents or traumas
Any counselling or treatment in the past
Do you know anything about your own birth or early days?
Rate your interest in sex
- High
- Moderate
- Low
- None
Do you have/had difficulty experiencing orgasm?
- Yes
- No
Does your partner experience problems, if so what?
Do you have a history of trauma/rape?
- Yes
- No
Did you receive support/help?
- Yes
- No
Reproductive Health History
How old where you when your periods started?
What was this like for you?
How long have you been trying for a baby?
If you’ve visited a GP or clinic for fertility, what diagnosis have they given you?
Have you ever been pregnant?
- Yes
- No
Have you ever had a miscarriage?
- Yes
- No
Please provide details of what stage of pregnancy and any details that you know.
Have you ever terminated a pregnancy?
- Yes
- No
Is the termination confidential? (i.e. is your partner aware?)
- Yes
- No
Please tell me about your experience of pregnancy
How many pregnancies have you had?
Please tell me what you feel comfortable sharing now about your experiences of birth
Please tell me about your post-natal experiences
Former Methods of Contraception
Pills
- Yes
- No
When and for how long
Patch
- Yes
- No
When and for how long
Injection
- Yes
- No
When and for how long
Condoms
- Yes
- No
When and for how long
IUD
- Yes
- No
When and for how long
Abstinence
- Yes
- No
When and for how long
Charting/NFP
- Yes
- No
When and for how long
Other Contraception
- Yes
- No
What, when and for how long
Date of last cervical smear
Smear results
Date of last period
Currently how long do they last?
Do you think your periods are...
- Light
- Heavy
- Average
Are your periods regular?
- Yes
- No
Have you ever experienced irregular cycles?
- Yes
- No
Do you experience any symptoms
- Painful periods
- Irregular periods (late or early)
- Dark thick blood at the beginning of the cycle
- Dark thick blood at the end of the cycle
- Dizzyness with period
- Headache or migraine with period
- PMS/depression with or before period
- Excessive period (>1 change of sanitary product an hour)
- Heaviness or pressure in lower pelvis with period
- Bloating or water retention with period
- Painful ovulation
- Failure to ovulate
Are any of these relevant to you?
- Varicose veins of the leg
- Tired weak legs
- Numb legs and feet when standing still
- Low back ache
- Constipation
- Endometriosis
- Polycystic Ovary Syndrome (PCOS)
- Ovarian cysts
- Breast cysts
- Uterine Polyps
- Fibroids (size and location if known)
- Bladder infection
- Vaginitis
- Frequent urination
- Vaginal yeast infection
- Dry vagina
- Chronic miscarriages
- Premature births
- STD (date and type)
- Exhaustion
- Drained
- Sleeplessness
- Emotional eating
- Emotional drinking
- Loss of smell/taste
- Skin disorders (acne, fungus, psoriasis
- Fainting
- High or low blood pressure
- Anxiety
- Asthma
- Herniated of bulging disc
- Ringing in the ears
- Swollen ankles/joints
- Sciatica
- Loss of memory
- Contact lenses/glasses
- Frequent colds/upper respiratory conditions
- Do you suffer from any areas of persistent pain or tension? If so, where?
Please give more details, where, dates, type etc.
What provides relief to any of the above?
What sort of sanitary products do you use?
- Tampons
- Pads
- Mooncup
- Other
Do you think you ovulate each month?
- Yes
- No
What makes you think you ovulate each month?
Are you aware of your fertile time?
- Yes
- No
Are you aware of your changing cervical secretions
- Yes
- No
Diet and digestion
How much water do you drink in a day? (pints)
How much caffine do you drink in a day? (cups)
Typical breakfast
Typical lunch
Typical dinner
Typical snacks
What are the worst things about your diet?
Which foods are your weakness?
Do you ever binge eat?
- Yes
- No
Do you experience bloating/gas/burps?
- Yes
- No
What foods do you think trigger this?
How often are your bowel movements?
Which of these apply to you
- Floating stools
- Sinking stools
- Constipation
- Loose stools
- Mucus in stools
- Pain when going
- IBS
Family History
Do you know anything about your mother’s experience of pregnancy, birth and the early days?
Any family history of:
- Infertility
- Fibroids
- Endometriosis
- Cancer
- Menstrual problems
- Early or problematic menopause
- PMS
What type of cancer?
Emotional , Spiritual and Lifestyle
What is your opinion of yourself?
What is your most negative emotion you feel?
When do you feel this?
What provides relief?
Do you meditate/pray/have a spiritual practice?
On a scale of 0 – 10 (0 being indifferent and 10 being the greatest) please rate yourself on the following:
Faith
Please enter a number from 0 to 10.
Hope
Please enter a number from 0 to 10.
Charity
Please enter a number from 0 to 10.
Generosity
Please enter a number from 0 to 10.
Grief
Please enter a number from 0 to 10.
Sense of fun
Please enter a number from 0 to 10.
Sense of humour
Please enter a number from 0 to 10.
Optimism
Please enter a number from 0 to 10.
Fear
Please enter a number from 0 to 10.
What activities or hobbies do you have that provide you with a sense of pleasure and accomplishment?
What changes would you like to achieve in 6 months?
What changes would you like to achieve in 12 months?
What do you do to relax?
How many hours do you sleep on a night?
Do you exercise
- Yes
- No
How many hours a week do you work?
How long is your commute?
What would you like to see change?
Any continuations or extra information:
Please read the Terms and Conditions which will open in a new page.
*
- I agree to the Terms and Conditions
Thank you for taking the time to fill in any of this form. If any of the questions have triggered an unwanted response before your appointment, please get in touch. By filling it in, you are giving me permission to work with you. If any in doubt, contact your GP.

Message Jay: glowfertility@gmail.com

Mobile: 07725035047 (sometimes it is not possible to take calls, so emails are preferable)

Skype clients: glowfertility
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Save and Continue Later

Personal Details

Medical or Other Practitioners

Reproductive Health History

Former Methods of Contraception

Diet and digestion

Family History

Emotional , Spiritual and Lifestyle

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