Basic Information

Information you provide is managed in accordance with our privacy policy

Age

Height (in cm)

Weight(in kg)

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Lifestyle

Do you smoke?

Yes No

How many units of alcohol do you drink per week ?

How would you rate your diet?

Healthy

Moderately healthy

Healthy

Somewhere in the middle.

How many times a week do you exercise ?

And how many minutes do you typically exercise ?

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Medical History

When did you last check your blood pressure ?

What was your last blood pressure reading (if known)? (in mmHg)

Please indicate any past medical issues or operations

Please list any family medical conditions

List any medication you take (including natural remedies)

List any drug allergies you may have

What are your current health concerns or goals?

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How did you hear about us?

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Woman's Health

(complete if relevant)

How would you rate your diet?

Healthy

Moderately healthy

Healthy

Somewhere in the middle.

How old were you at first menstrual period?

If not still having periods, how old were you when you had your last period?

Is your menstrual cycle typically regular?

Yes No

How many days does your menstrual cycle typically last? (eg. 28 days)

Which day of your cycle do your ovulate? (if known)

Have you had previous pregnancies or miscarriages?

Yes No

Do you have polycystic ovarian syndrome?

Yes No Not sure

Is there anything else you'd like to share?

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Family Planning

(complete if relevant)

Are you currently pregnant or breastfeeding or have you recently given birth?

Yes No Recently given birth

How many months have you been trying to conceive?

Have you or your partner had any previous fertility tests?

Yes No

Is there any other relevant information you'd like to share?

UPDATE

Health Profile

Basic Information

Lifestyle

Medical History

How did you hear about us?

Woman's Health

(complete if relevant)

Family Planning

(complete if relevant)