Fertility Questionnaire - Confidential
Many of these questions are optional, but all are incredibly helpful. Please give as much or as little information as you are comfortable in giving. All of your answers are confidential, and to help me build an accurate picture of your situation.
Full Name *
Your answer
Known As: *
Your answer
In as many or as few words as you wish, how can I help you?
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Age *
Your answer
Address *
Your answer
Telephone Number *
Your answer
Email Address *
Your answer
Relationship Status
Do you (or your partner) have children?
Your answer
Occupation
Your answer
How many hours a week do you work?
Your answer
Do you enjoy your job?
What is your height?
Your answer
How much do you weigh?
Your answer
Doctor's Name / Practice Address *
Your answer
When did you last visit the doctor, and for what? *
Your answer
Are you taking any medication? *
Required
If yes, please give details
Your answer
Are you taking any supplements / remedies? *
Required
If yes, please give details
Your answer
How would you describe your general health? *
Your answer
Have you had / are you having any other complimentary treatments for fertility? *
Required
If yes, please give details
Your answer
Have you ever been diagnosed with: *
Required
If yes, please give details and treament
Your answer
Do you smoke cigarettes? *
Do you drink alcohol? *
If yes, do you drink
Do you take recreational drugs? *
If yes, please give details
Your answer
How would you describe your diet? *
Your answer
Do you exercise? *
How many hours sleep do you get a night? *
Your answer
Do you have periods?
If no, please give details
Your answer
At what age did your periods start?
Your answer
How long is your cycle (number of days between periods)
Your answer
Is your cycle regular?
How many days is your period?
Your answer
Are your periods ever painful?
Are your periods
Do you ovulate every month?
Are you aware of your fertile time?
Do you monitor your cervical mucus?
Do you experience any premenstrual symptoms?
If yes, or sometimes, please give details
Your answer
Have you ever used contraception?
If yes, please give details (what and for how long)
Your answer
How long have you been trying for a baby?
Your answer
Have you seen your GP?
What tests / investigations have you had, and what was their outcome?
Your answer
What diagnosis did you receive?
Your answer
What tests / investigations has your partner had, and what was their outcome?
Your answer
Have you had any medical treatments for fertility? (eg IUI, Clomid, IVF) *
If yes, please give details (eg Date, Treatment, Clinic, Outcome)
Your answer
Is there anything else you feel I ought to know?
Your answer
How did you hear about me? *
Your answer
Where would you prefer to be seen? *
Please tick as many or as few as are appropriate:
Required
When would you prefer to be seen? *
Required
How would you like me to contact you? *
Required
Terms and Conditions
I am a fully qualified, registered and insured Clinical Hypnotherapist, Counsellor and Mind Coach. All my work is carried out in line with the code of ethics and conduct of the National Council for Hypnotherapy (NCH); a copy is available on their website.

Hypnotherapy and Counselling can be extremely effective; however there can be no ‘guarantee’ of a cure for any given condition. Therapy requires commitment and motivation from both the therapist and the client to achieve the best results and whilst I will always do my absolute best for you, I do not have a magic wand. My sessions contain a mixture of therapies and techniques, depending upon your individual needs. I will always discuss these with you.

Fees are charged by the session, with discounts available for block bookings, when paid in advance.

Sessions normally last 50 – 60 minutes, although 90 minute sessions are available where appropriate.

Cancelling an Appointment:

Please give as much notice as possible if you wish to change or cancel an appointment.

Less than 24 hours' notice will incur a charge of 50% of the fee with 100% being charged for non-arrival.

Arriving Late for an Appointment:

If you are running late, please let me know as soon as possible. I will do my best to accommodate this, but if I have an appointment immediately after yours, your session may need to be curtailed. The full fee will still be payable if your session has to be curtailed due to your late arrival.

Mutual Respect:

I undertake to treat you with respect and am always respectful of the trust you put in me. I will use best practice at all times in our mutual interest. In return, you undertake not to harm yourself, or me, or any property belonging either to me or any other person during our sessions. You agree not to come to sessions under the influence of alcohol or recreational drugs, except those medications prescribed by your doctor. If you do come to sessions under the influence of alcohol or recreational drugs, or if you demonstrate violent or abusive behaviour, I reserve the right to cancel the session and refuse any further therapy sessions.

I have read and accept the Terms and Conditions *
Required
GDPR Compliance
The details you provide are for the purpose of this enquiry only and will never be used for anything other than your treatment. Information you provide will be held securely by me, and will never be passed to a third party.

By ticking the boxes, you are agreeing to being contacted, by me in response to this enquiry, and to your details being held securely for the purpose of any treatment you undertake.

I consent to being contacted by Franca Hood in relation to this enquiry. *
Required
I consent to Franca Hood holding my details, securely for the purpose of my treatment *
Required
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