Microsoft word - ncq0005 - forsight questionaire.doc

QUESTIONNAIRE NCQ005 Last printed: 2005-06-14 (20:28:00) FORESIGHT PRE-CONCEPTION QUESTIONNAIRE
Female Partner:
Male Partner:

HAIR SAMPLE INFO (please give hair product details below):
If you require clarification concerning the information outlined above please contact your nearest qualified nutritional therapist for an appointment or contact: Ursula Fearn, MSc. Dip. ION BANT — Telephone: (01620) 826810, (07810) 673565 or (0131) 225 8092 or email: ursula@nutri-ception.co.uk (website: www.nutri-ception.co.uk). QUESTIONNAIRE NCQ005 Last printed: 2005-06-14 (20:28:00)
FEMALE REPRODUCTIVE HISTORY
Sex (child)
Birth weight
Sex (child)
Birth weight
Malformation(s) — please give details: Allergic il ness and other health problems with children: If you require clarification concerning the information outlined above please contact your nearest qualified nutritional therapist for an appointment or contact: Ursula Fearn, MSc. Dip. ION BANT — Telephone: (01620) 826810, (07810) 673565 or (0131) 225 8092 or email: ursula@nutri-ception.co.uk (website: www.nutri-ception.co.uk). QUESTIONNAIRE NCQ005 Last printed: 2005-06-14 (20:28:00)
INFERTILITY
Female: yes/no, number of years? _____ Male: yes/no, number of years? _____ Previous fertility treatment? yes/no — Success? yes/no
Please name any fertility drugs used (e.g. Clomid, Danazol): ___________________________
CONTRACEPTION
How long? _____________ Dates: _____________________________ Coil - pill - diaphragm - sheath - female condom - sponge Natural family planning - personal - none Have you been immunised for rubella? yes/no - when? ______ When Checked? ______ ENVIRONMENTAL TOXICITY PROFILE (please tick exposure accordingly):
If you require clarification concerning the information outlined above please contact your nearest qualified nutritional therapist for an appointment or contact: Ursula Fearn, MSc. Dip. ION BANT — Telephone: (01620) 826810, (07810) 673565 or (0131) 225 8092 or email: ursula@nutri-ception.co.uk (website: www.nutri-ception.co.uk). QUESTIONNAIRE NCQ005 Last printed: 2005-06-14 (20:28:00)
MALE FERTILITY STATUS
Have you had a sperm count? yes/no … if yes please state number of million: ________ % malformed: ________ % immotile: ________ clumping? yes/no In the past have you had (please tick if yes): mumps , non-specific uritis , Rubella , testicular cancer , varicoceal , vasectomy reversal Have you or do you use cannabis? yes/no. Have you been checked or treated for (please tick if yes and give details e.g. year etc.): If you require clarification concerning the information outlined above please contact your nearest qualified nutritional therapist for an appointment or contact: Ursula Fearn, MSc. Dip. ION BANT — Telephone: (01620) 826810, (07810) 673565 or (0131) 225 8092 or email: ursula@nutri-ception.co.uk (website: www.nutri-ception.co.uk). QUESTIONNAIRE NCQ005 Last printed: 2005-06-14 (20:28:00)
FEMALE GYNAECOLOGICAL HISTORY

DO or DID you suffer from any of the following:
Have you been checked or treated for (please tick if yes and give details e.g. year etc.): If you require clarification concerning the information outlined above please contact your nearest qualified nutritional therapist for an appointment or contact: Ursula Fearn, MSc. Dip. ION BANT — Telephone: (01620) 826810, (07810) 673565 or (0131) 225 8092 or email: ursula@nutri-ception.co.uk (website: www.nutri-ception.co.uk). QUESTIONNAIRE NCQ005 Last printed: 2005-06-14 (20:28:00)
DEFICIENCY SYMPTOM PROFILE (please tick accordingly):

ILLNESS PROFILE (please tick present or previous ailments accordingly):
M - F Anorexia
If you require clarification concerning the information outlined above please contact your nearest qualified nutritional therapist for an appointment or contact: Ursula Fearn, MSc. Dip. ION BANT — Telephone: (01620) 826810, (07810) 673565 or (0131) 225 8092 or email: ursula@nutri-ception.co.uk (website: www.nutri-ception.co.uk). QUESTIONNAIRE NCQ005 Last printed: 2005-06-14 (20:28:00)
DRUG USE PROFILE (tick regular use of):
THIS QUESTIONNAIRE ACKNOWLEDGES THE WORK OF FORESIGHT and Belinda Barnes at the Pre-conceptual Care Charity (Reg. Charity No. 279160) If you require clarification concerning the information outlined above please contact your nearest qualified nutritional therapist for an appointment or contact: Ursula Fearn, MSc. Dip. ION BANT — Telephone: (01620) 826810, (07810) 673565 or (0131) 225 8092 or email: ursula@nutri-ception.co.uk (website: www.nutri-ception.co.uk).

Source: http://clients.fadesign.net/nutriception/office/documents/pdf/NCQ05.pdf