Sims IVF New Patient Appointment Form

Sims logo
Please complete the following form including the medical history section. Upon receipt of this form you will be contacted to schedule an appointment. Please note that the new Fertility Check packages pricing is only applicable for those that book from 01/09/2021

If you are taking any form of hormonal contraception we recommend you book in for an initial consult instead of our fertility package so one of our Doctors can tailor your investigation plan as hormonal contraception can impact test results




Privacy Policy

I have read and understood the Sims IVF Privacy Policy and I agree to the processing of my personal data as per this policy. I am aware that I can contact dpo@virtushealth.ie if I have any queries regarding the processing of my personal data or if I wish to withdraw consent for this processing.

General Information














General information cont.














Female Patient Medical History

Please complete this form to the best of your knowledge. If there are any question you are uncertain about, do not worry. The details will be discussed with the doctor at the first appointment.

The form will take some time to complete. if you have any questions or queries, please do not hesitate to contact us.

If you have further information, medical records or otherwise, please bring them to the first appointment so that your doctor can review them.

BMI and Height information is required. This information will be re-confirmed in Clinic.



Have you ever undergone an operation? (If so, please give details of all operations including the year).








Female medical history continued





Social History







Family History



Mental Health Questions



Menstrual History










Gynaecology History








Obstetric History


Obstetric History

Please provide any information you can below










Pregnancy 1







Pregnancy 2







Pregnancy 3







Pregnancy 4







Pregnancy 5






Previous Treatment


Previous Treatment 1

Please provide as much information as you are able to











Treatment 2











Treatment 3












Treatment 4












Treatment 5











Male Medical History

Please complete this form to the best of your knowledge. If there are any question you are uncertain about, do not worry. The details will be discussed with the doctor at the first appointment. 

The form will take some time to complete. if you have any questions or queries, please do not hesitate to contact us. 

If you have further information, medical records or otherwise, please bring them to the first appointment so that your doctor can review them. 




Male Fertility/Andrology











Male Social History







Male Mental Health Questions



Male Surgical History










Your Partner


Your Partner












Female Partner Medical History



Have you ever undergone an operation? (If so, please give details of all operations including the year).








Female Partner medical history continued





Female Partner Social History







Female Partner Family History



Female Partner Mental Health Questions



Female Partner Menstrual History










Female Partner Gynaecology History








Female Partner Obstetric History


Female Partner Obstetric History

Please provide any information you can below










Female Partner Pregnancy 1







Female Partner Pregnancy 2







Female Partner Pregnancy 3







Female Partner Pregnancy 4







Female Partner Pregnancy 5






Female Partner Previous Treatment


Female Partner Previous Treatment 1

Please provide as much information as you are able to











Female Partner Treatment 2











Female Partner Treatment 3












Female Partner Treatment 4












Female Partner Treatment 5











Male Partner Medical History 





Male Partner Fertility/Andrology











Male Partner Social History







Male Partner Mental Health Questions



Male Partner Surgical History










Additional Comments



Authorisation

Your records are considered confidential and will not be released without your consent and signature.

I hereby authorise the Sims Fertility Clinic to release information to my GP and myself.