Name *

First Name

Last Name

Does this intefere with:

Sleep

Work

Relationships

Painful Periods

Yes

No

Painful Ovulation

Yes

No

Irregular Periods

Yes

No

Excessive Bleeding

(>1 pad/tampon per hour)

Yes

No

PCOS (Polycystic Ovarian Syndrome)

Polycystic ovarian syndrome, or PCOS, is a condition in which a woman's levels of the sex hormones estrogen and progesterone are out of balance. This leads to the growth of ovarian cysts (benign masses on the ovaries). PCOS can cause problems with a women's menstrual cycle, fertility, cardiac function, and appearance.

Yes

No

PCO (Polycystic Ovaries)

PCO disease is an hormonal problem that causes women various symptoms including: Irregular or no periods Acne Obesity, and Excess hair growth.

Yes

No

Fibroids

Many women are unaware they have fibroids because they don't have any symptoms. Women who do have symptoms (around one in three) may experience: heavy periods or painful periods tummy (abdominal) pain lower back pain a frequent need to urinate constipation pain or discomfort during sex

Yes

No

POF (Premature Ovarian Failure)

Premature ovarian failure (POF) is when a woman's ovaries stop working before she is 40. POF is different from premature menopause

Yes

No

Failure to Ovulate / Low Ovulation

The failure of the ovary to release an egg at the appropriate time in the menstrual cycle.

Yes

No

Low AMH

Anti-Müllerian Hormone, or 'AMH' as it is often called, is a hormone which is given off by developing follicles, which are egg sacs containing immature eggs.

Yes

No

Miscarriages

Yes, Once

Yes, Recurring

No

Lower Back Ache

Yes

No

Headaches

Yes

No

Dizziness

Yes

No

Change in bowels

e.g Constipation/Diarrhoea

Yes

No

Pain/Numbness in Leg

Yes, in left leg

Yes, in right leg

No

Dark thick blood during Menstruation

At Beginning

At End

No

Blood clots

Yes

No

Cramps

Yes, in left side

Yes, in right side

Yes, in lower abdomen

No

Heaviness of pressure in lower pelvis

Yes

No

Dragging Sensation

Yes

No

Increased Urination

Yes

No

Varicose Veins

Yes, in left leg

Yes, in right leg

No

Bladder Infections

Yes

No

Bladder Weakness

Yes

No

Frequent Urination

Yes

No

Cold Hands or Feet

Yes

No

Anxiety / Depression

Yes

No

Trouble with Sleep Onset

Yes

No

Trouble with Sleep Maintenance

Yes

No

Tightness in Chest

Yes

No

Difficulty Breathing into Abdomen

Yes

No

Constipation

(<1 per day)

Yes

No

Diarrhoea

Yes

No

IBS

Yes

No

Formed Bowel Movements

Sausage Like

Yes

No

Hard Bowel Movements

Yes

No

Non-Formed Bowel Movements (pellets)

Yes

No

Abdominal Pain

Yes, in left side

Yes, in right side

No

Are you under treatment for infertility i.e IVF

Yes

No

Have you had any surgery?

Yes, on abdomen

Yes, on lower back

No

Have you experienced Accidents or Traumas?

Yes

No

Have you experienced injuries?

Yes, to Sacrum

Yes, to tailbone

Yes, to head

No

Recent procedures

(<6 months) - if yes give detail below

Yes

No

High/low blood pressure

Yes

No

Other relevant medical conditions

If yes give detail below

Yes

No

Other Events

Terminations?

Miscarriages?

Ectopic Pregnancies?

None of the Above.

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Yes

No

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Yes

No

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No

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