FertilityCare lifefertilitycare.co.uk
Assessment Form for the Life FertilityCare
Treatment Programme

Please complete:
SECTIONS 1 and 2 for Treatment (Infertility Treatment is available to married couples only)

Where information is required - marked with * - you will need to make an entry before you can send the form (this may mean entering 'None' or 'No')


In taking the time to complete and send the assessment form you are providing us with the information we need to be able to advise you on whether or not you would benefit from the Life FertilityCare programme. Any medical information you give us regarding your health and your personal details will be used for assessment purposes only and kept strictly confidential. Life FertilityCare conforms to the UK Data protection Act 1998 and the healthcare Commission privacy and confidentiality policies.

NOTE: Treatment can generally only accessed by residents of the United Kingdom - if you reside outside the UK you can find out more about body-friendly treatment from the following websites: for United States of America visit naprotechnology.com; for Australia visit fertilitycare.com.au; for Ireland visit fertilitycare.ie
 
SECTION 1 - General Assessment
*Required (fields that must completed before sending the form)
 
Your personal details
First Name* Woman    Man
Last Name* Woman    Man
Marital Status Single    Married    Co-habiting
Date of Birth (DD/MM/YYYY) Woman Man
e-mail*
Home Phone *
Work Phone
Mobile Phone
Street Address*
 
Town/City*
County*
Postcode*
COUNTRY*
 
Which is most relevant? Click the checkbox(es) below
Overcoming infertility Women's healthcare
Recent miscarriage Natural family planning
Your general gynaecological / obstetric history relating to your enquiry Other relevant information to do with lifestyle
eg stress, bereavement, relationships
   
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SECTION 2 - Procedures and Treatments

NB: This section must be completed for all enquiries regarding fertility treatment - we need this information in order to make an accurate assessment.

It is essential that you give us information relating to specific procedures and treatments, dates they have been carried out and drugs taken. Copies of Seminal Fluid Analysis (SFA) results can be obtained via your GP or fertility specialist.

*Required (fields that must completed before sending the form)
 
Which if any, of the following procedures have been carried out?
Click the relevant checkbox(es) below and give dates and further information if relevant
 
Laparoscopy* enter Date carried out or None
Are your fallopian tubes clear? enter YES or NO (if known)
Are your ovaries healthy? enter YES or NO (if known)
Have polycystic ovaries been identified? enter YES or NO (if known)
Has endometriosis been diagnosed? enter YES or NO (if known)
if Yes, enter Mild, Moderate or Severe
How have the above conditions been treated?
Have adhesions been identified? enter YES or NO (if known)
If yes, how have they been treated
   
Hysterosalphinogram/Hycosy* enter Date carried out or None
Did the Hysterosalphinogram/Hycosy indicate the fallopian tubes were clear? enter YES or NO (if known)
     
Hysteroscopy* enter Date carried out or None
Was anything found using Hysteroscopy? enter YES or NO (if known)
If yes, describe the findings
   
Other gynaecological procedures/treatments/surgery*
eg ultrasound scans
enter YES or NO
   
Blood Test - FSH* NB: Enter 'YES' if you have been tested and are unsure of the date

enter Date or YES, or NONE    Result
   
Blood Test - LH* NB: Enter 'YES' if you have been tested and are unsure of the date

enter Date or YES, or NONE    Result

   
Seminal Fluid Analysis* if Yes, enter Sperm Count result in figures
or enter NONE
Sperm Normal Morphology (% result) % (enter figures)
Sperm Motility (% result - enter figures) % Slow    % Moderate % Rapid
 
Which if any, drugs and treatments have you already received?
Click on the relevant checkbox(es) below and give dates and further information where possible
   
Have you had any of these treatments?  
IUI* enter number of treatments or 'ZERO'
IVF/ICSI* enter number of treatments or 'ZERO'
Do you have frozen embryos?* enter YES or NO
Have you been treated with Clomiphene/Clomid?* enter YES or NO
How many cycles of Clomiphene/Clomid in total? Total number of cycles (enter figure)
   
List any other drugs taken for fertility treatments
   
How did you find out about us?
(Press Ad, Magazine Ad, from a friend, Search engine, via a website link)
 
Check details and click send button
Click to clear all details
Thank you for completing the form - you will receive an email from us advising you on whether or not you may benefit from the Life FertiltyCare Programme.
 
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