Questionnaire

 

To prepare for your consultation please complete this questionnaire. Not all the questions are compulsory however we ask you provide as much information as possible.

All details provided are treated with utmost confidentiality and are for solely for the clinical use of Dr Agrawal. They will not be shared with anybody else.

Main contact's details

Email:
Your Name:

Female's Details
Age:
Marital Status:
Resident in which country:
Height:
Weight:
Date last period began:
Interval between periods:
Shortest:
Longest:
Period length:
Details of previous pregnancies and/or deliveries:
Gynecological problems or operations:
Cervical smear details:
Contraception used:
Details of any current or past medical or sugical conditions:
Details of any family medical problems:
Details of any other current medication:
Details of any allergies:
Do you smoke?
If so how many?
Alcohol intake:
Recreational drugs:
Any other information:

Male's Details
Age:
How long together:
Have you fathered before?
Details of any current or past medical or sugical conditions:
Details of any other current medication:
Details of any allergies:
Have you had a Semen Analysis?
What were the results?
Do you smoke?
If so how many?
Alcohol intake:
Recreational drugs:
Any other information: