NATURAL HEALTH CONSULTING Janet Comeskey N.D Dip Herb Med. MNZAMH Fertility Information Questionnaire Who can we thank for referring you to our practice? What are your concerns regarding you or your partners fertility? Fill in one questionnaire each partner Has anyone in your family suffered from infertility, heart disease, diabetes, hypertension or depression? Or anything else that may be relevant.
Are you on prescription medication?If so please list them.
Have you taken antibiotics in the last 12 months?
Do you take any supplements or herbal remedies?If so please list them.
Have you been hospitalised OR had anesthesia recently?
If you are female have you used any form of hormonal contraception?
If YES to any of the above, please provide any relevant details: Give details of present or past contraception used:
ARE YOU EXPOSED TO CHEMICALS IN YOUR JOB/HOME? Or in the past? Eg cleaners, car mechanics, painter etc
Do you have or have you had any of the following: If YES to any of the above, please provide any relevant details below: Are your symptoms constant or do they come and go? Do you have any current health problems that have not been covered so far? ______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ ____________________________________________________________________________________ Have you ever been tested for? If unsure insert? Miscarriage Hormones If YES to any of the above, please provide any relevant details below: Lifestyle questions
detergents, traffic or cigarette smoke?Do you take recreational
occur and how long has this be happening for?
FERTILITY QUESTIONS HAVE YOU ALREADY STARTED TRYING TO CONCIEVE? IF SO FOR HOW LONG? HAVE YOU HAD ANY CHILDREN? PLEASE SPECIFI Y LIVE BIRTH/MISCARRIAGE/TERMINATION/PREMATURE/ SMALL FOR DATES OR PERINATAL DEATH. PLEASE STATE ANY COMPLICATIONS OR DIFFICULTIES CONCIEVING: FEMALE QUESTIONAIRE: if unsure of any question insert?
Have you charted your basal body temperate? YES/NOAre you or have you taken fertility drugs? YES/NO give details……………………………………Have you observed your cervical mucus changes? YES/NOIf yes, does it change mid-cycle? Never/Sometimes/Usually/Always?
Have you had any of the procedures below: Laparoscopy: YES/NO result and date. Condition of left tube: CLEAR/BLOCKED/SCARRED/ADHERED Condition of right tube: CLEAR/BLOCKED/SCARRED/ADHERED Are there any other adhesions to other parts of your reproductive system? YES?NO Is there any evidence of endometriosis? YES?NO Have you had a recent pap smear test? give result and date……………………………………… Have you had cervical erosion/cone biopsy/lazer treatment/ cauterizations? YES/NO If yes give dates and details……………………………………………………………………………… Have you had an ultrasound: YES/NO give results and date………………………………………. Have you had a hysterosalpingogram: YES/NO give results and date……………………………. Left tube: CLEAR/BLOCKED/PARTIALLY BLOCKED Right tube: CLEAR/BLOCKED/PARTICALLY BLOCKED Have you undertaken ANY treatment to assist conception? YES/NO give details and dates:
…………………………………………………………………………………………………………………Do you have anymore treatments planned? YES/NO give details and dates below:
Have you suffered from any of the following conditions: please circlePelvic inflammatory disease endometriosis painful periodsPolycystic ovarian syndrome ovarian cysts fibroidsCervical changes breast lumps breast cancervagina thrush cervical cancer polyps
Have you previously had any of the following fertility investigations?Semen analysis YES/NO give details and dates:………………………………………………………Who ordered this?. Have you had any other tests done? YES/NO give details. Have you had a thyroid function test? Yes/No give details………………………………………….
Have you had any of these conditions? Please circleundescended testes
sexually transmitted diseases (please specify)
Have you or your partner undergone a post-coital test? YES/NO give dates and details………
Have you or your partner undergone a post-coital test with a different partner? YES/NOGive relevant details
Have you or your partner undergone a sperm/cervical mucus contact test? YES/NO give dates and details
Have you been tested for sperm antibodies? YES/NO give details and datesPlease include any reports you may have. Thank-you
I recognise that by providing my practitioner with complete details of my health history, I am enabling them to regard all aspects of my previous and current health status in my treatment. By not disclosing vital information this may have an impact on the success of my treatment outcomes. I have answered all of the questions to best of my ability and I understand the statement above. All of my case details are confidential and will be treated as such by my practitioner.
As a client I will endeavor to keep my appointment times.
Practitioner: _________ ___________________________Date: _____________________
If unable to keep your appointment please inform me 24 hours prior so that others can use this appointment time. Thank-you
Studiul asupra aplicabilit ˘atii sistemului deachizitie biometric în stabilirea parametrilorpsihomotorii pentru posesorul unei set deAlegerea lotului de subiecti a avut în vedere structurarea unorgrupuri care prezint ˘a particularit ˘ati din punct de vedere alanalizei avute în vedere. În acest sens au fost selectionatiindivizi de nationalit ˘ati diferite precum si cu anumite grade de
Eur opean Rev iew for Med ical and Pharmacol ogical Sci ences Secondary hemophagocytic lymphohistiocytosis in zoonoses. A systematic review A. CASCIO1-3, L.M. PERNICE1, G. BARBERI1, D. DELFINO1, C. BIONDO4, C. BENINATI4, G. MANCUSO4, A.J. RODRIGUEZ-MORALES3,5, C. IARIA2,6 1Department of Human Pathology, Policlinico “G. Martino”, Messina, Italy 2AILMI (Associazione Italiana per l