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    Cohabiting
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
 
Are your fallopian tubes clear?* enter YES or NO (if known)
Comment
   
Seminal Fluid Analysis* enter Date carried out or None
If yes, describe the findings
   
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)
   
Provide details of any other relevant information
   
How did you find out about us?
(internet, advertisement, article, LIFE charity, friend, Fertility Show, newspaper etc)
 
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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