Please complete the following form to register for the fertility test package at Sims IVF

Please indicate which clinic you would like to make your appointment

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.

I agree to the Sims IVF Privacy Policy

General Information

Patient First Name

Patient Last Name

Maiden name (if applicable)

Gender

Date of Birth

Full postal address

Personal email address

Mobile number

General information cont.

Nationality

Occupation

Do you have health insurance?

PPS Number

Known allergies

How did you hear about the Fertility Testing Package?

GP details

GP name

GP Address

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.

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

Operations

Are you currently on any medications?

How long have you been trying to conceive?

Have you used contraception before?

Are you currently attending a medical doctor or being treated for an illness or medical condition?

Have you had any illness or been treated for a medical condition in the past?

Do you have any general medical complaints at present?

Are you currently using any non fertility medication?

Social History

If you smoke, how many cigarettes do you smoke per day?

If you are no longer a smoker, when did you give up smoking?

If you drink alcohol how many units do you consume per week?

Do you or have you taken any form of recreational drugs?

Family History

Has a member of your immediate family died from a chronic illness or disease?

Are there any significant inherited diseases or genetic conditions in your family that you are aware of?

Height

Weight

Menstrual History

At what age did you get your first period?

Do you get mid-cycle discomfort or vaginal mucus at your fertile time (ovulation)?

Do you use a pad or a tampon or both?

Do You Get Clots With Your Period?

Are your periods excessively heavy or painful? If they are painful, what painkillers do you take?

Do you notice bleeding between periods?

How often do your periods come?

How long do they generally last?

Date of Last Menstrual period?

Obstetric History

Have Been Pregnant Before

Obstetric History

Please provide any information you can below

Number Of Pregnancies

Number Of Deliveries

Number Of Live Births

Number Of Term Pregnancies 38-42 Weeks

Number Of Preterm Pregnancies

Number Of Ectopic Pregnancies

Number Of Spontaneous Abortions

Number Of Therapeutic Abortions

Number Of Still Births

Number Of Neonatal Deaths

Previous Treatment

Have you had previous fertility treatment

If yes, please provide details

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.

Are You Currently On Any Medications?

Do You Have Any General Medical Complaints At Present

Have You Had Any Illnesses Or Been Treated For Any Medical Condition In The Past

Are You Currently Attending A Medical Doctor Or Being Treated For A Medical Condition

Weight

Height

Male Fertility/Andrology

Have You Ever Had A Semen Analysis Carried Out

If Yes What Was The Result

If Yes, have you had any difficulty producing a sample in a clinic setting?

Have You Been Responsible For Any Pregnancies In The Past Number

Have You Ever Experienced A Groin Injury Or Undergone Groin Surgery

Have You Any History Of Operations Involving The Reproductive System

Do You Have Undescended Testicles

Did You Ever Have Mumps

If Yes Was This As A Child Or An Adult

Male Partner: Do You Have Any Concerns About Your Sexual Life

Male Social History

If you smoke how many cigarettes do you smoke per day?

If you are no longer a smoker, when did you give up smoking?

If you drink alcohol, how many units do you consume per week?

Do you or have you taken any form of recreational drugs?

Your Partner

Add partners details?

YesNo, not applicable

Your Partner

Partners Gender

Partners First Name

Partners Lat Name

Partners Date of Birth

Partners mobile telephone

Partners email address

Partners occupation

Partners known allergies

Partners GP name

Partners GP address

Male Partner Medical History

Are You Currently On Any Medications?

Do You Have Any General Medical Complaints At Present

Have You Had Any Illnesses Or Been Treated For Any Medical Condition In The Past

Are You Currently Attending A Medical Doctor Or Being Treated For A Medical Condition

Height

Weight

Male Partner Fertility/Andrology

Have You Ever Had A Semen Analysis Carried Out

If Yes What Was The Result

If Yes, have you had any difficulty producing a sample in a clinic setting?

Have You Been Responsible For Any Pregnancies In The Past Number

Have You Ever Experienced A Groin Injury Or Undergone Groin Surgery

Have You Any History Of Operations Involving The Reproductive System

Do You Have Undescended Testicles

Did You Ever Have Mumps

If Yes Was This As A Child Or An Adult

Male Partner: Do You Have Any Concerns About Your Sexual Life

Male Partner Social History

If you smoke how many cigarettes do you smoke per day?

If you are no longer a smoker, when did you give up smoking?

If you drink alcohol, how many units do you consume per week?

Do you or have you taken any form of recreational drugs?

Female Partner Medical History

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

Operations

Are you currently on any medications?

How long have you been trying to conceive?

Have you used contraception before?

Are you currently attending a medical doctor or being treated for an illness or medical condition?

Have you had any illness or been treated for a medical condition in the past?

Do you have any general medical complaints at present?

Are you currently using any non fertility medication?

Female Partner Social History

If you smoke, how many cigarettes do you smoke per day?

If you are no longer a smoker, when did you give up smoking?

If you drink alcohol how many units do you consume per week?

Do you or have you taken any form of recreational drugs?

Female Partner Family History

Has a member of your immediate family died from a chronic illness or disease?

Are there any significant inherited diseases or genetic conditions in your family that you are aware of?

Female Partner Menstrual History

At what age did you get your first period?

Do you get mid-cycle discomfort or vaginal mucus at your fertile time (ovulation)?

Do you use a pad or a tampon or both?

Do You Get Clots With Your Period?

Are your periods excessively heavy or painful? If they are painful, what painkillers do you take?

Do you notice bleeding between periods?

How often do your periods come?

How long do they generally last?

Date of Last Menstrual period?

Female Partner Obstetric History

Have Been Pregnant Before

Female Partner Obstetric History

Please provide any information you can below

Number Of Pregnancies

Number Of Deliveries

Number Of Live Births

Number Of Term Pregnancies 38-42 Weeks

Number Of Preterm Pregnancies

Number Of Ectopic Pregnancies

Number Of Spontaneous Abortions

Number Of Therapeutic Abortions

Number Of Still Births

Number Of Neonatal Deaths

Female Partner Previous Treatment

Have you had previous fertility treatment

If yes, please provide details

Additional Comments

Any additional comments

Privacy Policy

General Information

General information cont.

GP details

Female Patient Medical History

Female medical history continued

Social History

Family History

Menstrual History

Gynaecology History

Obstetric History

Obstetric History

Previous Treatment

Male Medical History

Male Fertility/Andrology

Male Social History

Male Surgical History

Your Partner

Your Partner

Male Partner Medical History

Male Partner Fertility/Andrology

Male Partner Social History

Male Partner Surgical History

Female Partner Medical History

Female Partner Medical History Continued

Female Partner Social History

Female Partner Family History

Female Partner Menstrual History

Female Partner Gynaecology History

Female Partner Obstetric History

Female Partner Obstetric History

Female Partner Previous Treatment

Additional Comments