Step 1 of 3 33% HiddenUntitled4545 HiddenDatestamp DD slash MM slash YYYY Token number(Required) What best describes your situation? I'm a new patient I've completed this more than 6 moths ago I'm addressing a new health issue Which of the answers below is the closest match to the main issue you'd like to address?(Required)Please choose the issue that is most important to address first. Injury or pain Fertility (I'm a female patient) Fertility (I'm a male patient) Women's health (not trying to concieve) Stress / anxiety / depression Other Date of birth:(Required)Day _ _12345678910111213141516171819202122232425262728293031Month _ _123456789101112Year _ _20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920HiddenAgeYour age is calculated from the date of birth aboveSex at birth Female Male Other EthnicityPlease select all that apply NZ Maori NZ European Chinese Indian Other Asian Latin American Middle Eastern European African Other Work status Employed Full-Time Employed Part-Time Homemaker Disabled Retired Student Prefer Not to Answer OccupationIn case you're not currently employed, please tell us your past occupation which may have an influence on your current health. Marital status Single Married or De Facto Divorced Widowed Other Your GP and / or SpecialistYour GP's name and phone number (or address/name of the clinic) Height (in centimetres)Weight (in kilograms)HiddenBMIDo you suffer from allergies Yes No List any allergies you have Current medicationsname of medication/dose/reason for taking. Please include herbal medications and any supplements in therapeutic dose. Do you consume any of the followingUsed to in pastNeverRarelyWeeklyDailyFew times a daySmoke tobaccoAlcoholVapeRecreational drugsPhysical activityPlease tick all that apply My job is physically demanding I exercise more than 10 hours a week I exercise 4 to 10 hours a week I exercise 1 to 4 hours a week I exercise less than an hour a week I hardly get any exercise Medical historyselect all that apply (including relevant family history) no medical history cardiac cancer ears, eyes, nose, throat endocrine gastrointestinal genitourinary musculosceletal hepatic neurologic respiratory pulmonary psychiatric sepsis vascular other Medical history detailPlease briefly detail the medical history you have ticked aboveStress?please tick any that apply yes, stressed at work yes, stressed at home I suffer from anxiety Please rate your stress level over the last few weeks Low Medium High Extreme Please rate your anxiety level over the last few weeks Low Medium High Extreme HiddenTCMYour sleepUsuallySometimesRarelyI am satisfied with my sleepI wake up restedI spend less than 30 min awake at night, including the time it takes to fall asleepI stay awake all day without dozingI am normally asleep between 2am and 4amMy sleep is undisturbed by dreamsHow many hours of sleep do you normally get each night? I work night shifts No Yes Other I feel happy, calm/balanced Most of the time Only several days a week Not at all I feel fatigued Almost never / only when I work too much Only several days a week Not at all Appetite Normal Excessive Lack of appetite Specific food cravings Bowel motion Normal Frequent constipation Frequent loose stools Alternating constipation & loose stools Thirst Normal Other Perspiration Normal Other In a room with other people I normally feel Colder than others Warmer than others Nor colder nor warmer HeadachesHow often do you suffer from headaches? Never Every day Once a week 2 to 3 times a week Once a month 2 to 3 times a month Less than once a month Other Headaches intensityIntensity 1 slight pain to 10 pain so severe you can't tolerate 1 2 3 4 5 6 7 8 9 10 Headaches: LocationTick all that apply Entire head Frontal / forehead Vertex / top of the head Temporal / temples Behind the eyes Occipital (back of the head) Did you get a menstrual bleeding in last 90 days? Yes No What is the date of your last period? Do you know the reason your cycle stopped?FertilityAre you trying to conceive? Yes Yes, in the near future No How long have you been trying? Did you or your partner have a diagnosis related to infertility? Yes No Diagnosis:Did your/your partners' diagnosis include any of the following (tick all that apply) unexplained infertility advanced maternal age PCOS anovulation blocked Fallopian tubes fibroids or polyps endometriosis pelvic adhesions pelvic abnormalities male factor infertility History of fertility treatments:Have you had any of the following treatments No previous treatment Clomophene/Clomid or Letrozole IUI IVF ICSI Lipiodol flushing Tubal operations Other Details of the treatments:Could you please briefly tell us dates of previous treatements and outcomesDo you have a single male partner with whom you're trying to conceive?(Required) Yes No / I'm single No - I'm in a homosexual relationship Choose not to answer Other Male partnerHow long have you been living together? Did your partnerTick all that apply Father children Had his sperm tested Sperm test details:Could you briefly give some detail about the the outcome of the test, how long ago was the test done?Vaginal lubricants?If trying to conceive naturally, do you use vaginal lubricants? no yes, K-Y®, Durex or similar yes, canola oil (it has been shown not to harm sperm) yes, the "sperm friendly" ones from the chemist (like Pre-Seed) Please note, that supermarket and some pharmacy range lubricants may contain spermicides, which actually aid to prevent conception. Canola oil and some pharmacy range lubricants have been shown to be a safe alternative in some studies. Your cycleDo you ovulate yes (on my own) yes (with help of medications only) no I don't know for sure Other Ovulation dayOn what day of your cycle do you ovulate? Length of menstrual cycleWhat's the length in days of your menstrual cycle (including variation)? Example: 24-35 days The length of the menstrual cycle is the time between the first day of your menstrual period and the first day of your next menstrual period. Duration of menstrual bleedingHow many days does your menstrual bleeding last (excluding spotting)? Are your periods painful?0 - no pain, 1 - slight pain to 10 - unbearable pain 0 1 2 3 4 5 6 7 8 9 10 How heavy is your menstrual bleeding?1 - light to 5 - heavy 1 2 3 4 5 Blood colour and consistencyPlease tick all that apply light red bright red dark red purple brown black some clotting a lot of clotting Do you experience premenstrual tension? no or very light one sometimes / moderate often / severe Do you experience any of these symptoms? breast tenderness before period spotting or bleeding between periods face breaking out before period premenstrual lower back pain bowel movements become lose before period How is your libido?Libido refers to sex drive or desire for sexual activity. 1 - low to 5 - high. 1 2 3 4 5 Reproductive health historyDid you have any of the following: cervical biopsy, operation, cauterisation or conization veneral disease regular yeast infections chlamydia infection chronic vaginal discharge sores on your genitalia pelvic inflammatory disease If any of above questions are current, please detail:Have you ever been pregnant? no yes, I have child/children miscarriage(s) termination(s) D&C Children:Could you please tell about the age of the child(ren) and if he/she was conceived naturally. Miscarriages, terminations and D&CIf relevant, could you please give a little more detail about the above. Hormone Laboratory tests?Did you have hormone laboratory tests performed? yes no Hormone test resultsCould you please outline the results of these testsDietPlease tick all that apply I eat LESS than 3 portions of vegetables a day I am a vegetarian or eat meat less than once a week I follow low GI diet I follow Mediterranean diet I do not avoid sugars I drink more than one cup of coffee daily I do NOT take folic acid (or prenatal supplement) If you follow any specific diet, please tell us brieflyPain / injuryWhat is the site of your pain or injury?Where does it hurt? Please rate intensity of your painIntensity 1 slight pain to 10 pain so severe you can't tolerate 1 2 3 4 5 6 7 8 9 10 Quality of pain sharp stabbing burning dull aching cramping throbbing agonising nagging tingling numbness weakness touch sensitive spasm shooting When do you get the pain? continuously activity related night pain unpredictable What makes the problem/pain better?What makes the problem/pain worse?How long has the pain/ problem been present? Has the problem/ pain worsened recently? Yes No Please describe how recently it got worseHow much do these symptoms interfere with your day-to-day functioning?Is this aPlease tick all that apply ACC registered injury Back pain Neck pain ACC claim number How did the injury happen? Please give precise description.Did you have a fall, or did you perhaps strain yourself while lifting something? Did it result in immediate pain? Date of injury MM slash DD slash YYYY Red flagsPlease tick all that apply Significant trauma History of cancer Weight loss Intravenous drug use Fever Steroid use Pain gets worse when lying down Please detail any red flags you ticked aboveNeurological deficits numbness weakness pins and needles loss of coordination/balance a change in bowel and/or bladder habit other sensory alteration Previous treatmentPlease tick all that apply physiotherapy chiropractic/osteopathy acupuncture surgery injections bracing other X-rays or tests done for this issue: X-rays MRI CT scan Bone scan Other HiddenPlease tell us about your conditionYour condition:Could you please tell us about your condition and what you'd like to achieve with our help. Your health goals:What is your immediate and long term plan? Male fertilityAre you and your partner trying to conceive? yes no, but in the near future no How long have you and your partner been trying to conceive? Do you or your partner have a diagnosis related to infertility? Yes No Diagnosis:Did your/your partners' diagnosis include any of the following (tick all that apply) male factor infertility unexplained infertility advanced maternal age PCOS anovulation blocked Fallopian tubes fibroids or polyps endometriosis pelvic adhesions Male infertility diagnosisDoes your male factor infertility diagnosis include any of the following (tick all that apply) varicoceles no sperm (azoospermia) low sperm count (oligospermia) poor sperm motility (asthenozoospermia) retrograde ejaculation immunologic infertility sperm antibodies hyperprolactinemia genital tract infection low testosterone chromosome defects (cystic fibrosis, Kallmann's syndrome and Kartagener's syndrome) undescended testicles Have you had your sperm tested? Yes No Sperm test details:Could you briefly give some detail about the outcome of the test, how long ago was the test done?Have you had any fertility related blood tests done? yes no Blood test details:Could you briefly give some detail about the the outcome of the test, how long ago was the test done?HiddenMale fertilityCurrently you and your partner are trying to conceiveTick all that apply naturally undergoing IUI your partner is taking Chlomid/Letrozole IVF/ICSI other Has your partner been pregnant with you? no yes, we have child/children miscarriage(s) termination(s) Has your partner conceived followingTick all that apply naturally, after the intercourse with you IUI using your sperm IVF using your sperm IVF with ICSI using your sperm IUI/IVF using donor sperm other Have you ever had a pregnancy with another partner? Yes No When did the last pregnancy happen? Has the above pregnancy happen followingTick all that apply intercourse with you IUI using your sperm IVF using your sperm IVF with ICSI using your sperm other Reproductive health historyHistory of surgeries?Tick all that apply vasectomy surgical intervention for twisted testes testes surgically brought to the scrotum any other surgery to the testes hernia operation bladder surgery other surgery Please briefly describe what kind of surgery you had and when.Have you ever had any testicular injuries?e.g. getting kicked in testes, motorcycle or bike accident that injured your testes. yes no Have you ever been treated with chemotherapy? Yes No Are you diagnosed withTick all that apply diabetes high blood pressure abnormal cholesterol STI / sexually transmited infection What Sexually Transmitted Infection (STI) were diagnosed with? Have you had a high fever within the last year?Fever higher than 39 degrees C can severely impair semen quality and even cause temporary loss of sperm. Yes No Have any of your blood relatives had difficulty to conceive? Yes No Do you have problems with erections or ejeculation? Yes No How is your libido?Libido refers to sex drive or desire for sexual activity. 1 - low to 5 - high. 1 2 3 4 5 Lifestyle factorsHave you been recently exposed to large amount of chemicals, pesticides, or radiation? Yes No Do you frequently use sunscreen antibacterial soap antibacterial toothpaste antibacterial mouthwash tanning products Note: sunscreen and antibacterial products commonly contain hormone-disrupting chemicals, which may have adverse effects on sperm. Research fertility-safe products here. Journal referenceHave you ever usedTick all that apply anabolic steroids body building drugs Vaginal lubricants?If trying to conceive naturally, do you use vaginal lubricants? no yes, K-Y®, Durex or similar yes, canola oil (it has been shown not to harm sperm) yes, the "sperm friendly" ones from the chemist (like Pre-Seed) Please note, that supermarket and some pharmacy range lubricants may contain spermicides, which actually aid to prevent conception. Canola oil and some pharmacy range lubricants have been shown to be a safe alternative in some studies. DietPlease tick all that apply I eat LESS than 3 portions of vegetables a day I eat red meat daily I have meat less than once a week I follow low GI diet I follow Mediterranean diet I eat potatoes, rice, bread or sweets daily My diet is rich in Vitamin A Important lifestyle factorsPlease tick all that apply have hot baths/ pools or sauna cycle regularly ever wear briefs (as opposed to loose boxers) sit long hours at work or home exposed to high temperatures at work In the past week, have you been feeling any of the following:Don’t take too long over your replies: your immediate is best.I still enjoy the things I used to enjoy:(Required) Definitely as much Not quite so much Only a little Hardly at all I feel tense or 'wound up'(Required) Most of the time A lot of the time From time to time, occasionally Not at all I get a sort of frightened feeling as if something awful is about to happen:(Required) Very definitely and quite badly Yes, but not too badly A little, but it doesn't worry me Not at all I can laugh and see the funny side of things:(Required) As much as I always could Not quite so much now Definitely not so much now Not at all Worrying thoughts go through my mind:(Required) A great deal of the time A lot of the time From time to time, but not too often Only occasionally I feel cheerful:(Required) Not at all Not often Sometimes Most of the time I can sit at ease and feel relaxed:(Required) Definitely Usually Not often Not at all I feel as if I am slowed down:(Required) Nearly all the time Very often Sometimes Not at all I get a sort of frightened feeling like 'butterflies' in the stomach:(Required) Not at all Occasionally Quite often Very often I have lost interest in my appearance:(Required) Definitely I don't take as much care as I should I may not take quite as much care I take just as much care as ever I feel restless as I have to be on the move:(Required) Very much indeed Quite a lot Not very much Not at all I look forward with enjoyment to things:(Required) As much as I ever did Rather less than I used to Definitely less than I used to Hardly at all I get sudden feelings of panic:(Required) Very often indeed Quite often Not very often Not at all I can enjoy a good book or radio or TV program:(Required) Often Sometimes Not often Very seldom HiddenAnxietyHiddenDepression Personal detailsName* optional First Last Email* optional Phone* optional HiddenIP address
