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Fertility Tests

Ultrasound Scanning

Tubal Patency Check

Hormone Blood Tests

Semen Analysis

Other Tests

First Step Fertility Package

Fertility Treatments

Follicle Tracking

Ovulation Induction

Intrauterine Insemination

IVF & ICSI

Frozen Embryo Transfer

Surgical Sperm Retrieval

Surrogacy

Male Factor

Semen Analysis

Supplementary Tests

Sperm Freezing

Advanced Sperm Selection

Surgical Sperm Retrieval

MicroTESE

Donor Services

Donor Sperm

Reciprocal IVF

Resources

Fertility Preservation

Egg Freezing

Sperm Freezing

Embryo Freezing

Before or after cancer

Children & Young Adults

Late Adolescent Fertility Preservation

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Genetics programme

Carrier Genetic Screening

PGT-A

PGT-M

PGT-SR
GP Info
Resources
- News & Events
Payment
Patient Portal
Contact Us
Book a consultation
View our pricelist

Home
About
Patient Info
Treatments & Services
Fertility Tests

Ultrasound Scanning

Tubal Patency Check

Hormone Blood Tests

Semen Analysis

Other Tests

First Step Fertility Package

Fertility Treatments

Follicle Tracking

Ovulation Induction

Intrauterine Insemination

IVF & ICSI

Frozen Embryo Transfer

Surgical Sperm Retrieval

Surrogacy

Male Factor

Semen Analysis

Supplementary Tests

Sperm Freezing

Advanced Sperm Selection

Surgical Sperm Retrieval

MicroTESE

Donor Services

Donor Sperm

Reciprocal IVF

Resources

Fertility Preservation

Egg Freezing

Sperm Freezing

Embryo Freezing

Before or after cancer

Children & Young Adults

Late Adolescent Fertility Preservation

Transgender Services

Genetics programme

Carrier Genetic Screening

PGT-A

PGT-M

PGT-SR
GP Info
Resources
- News & Events
Payment
Patient Portal
Contact Us
Book a consultation
View our pricelist

Book a consultation

Female Screening Form – Gynaecology

Home / Female Screening Form – Gynaecology

Female Screening Questionnaire (Gynaecology)

First Name*
Last Name*
Email Address*
If future eConsents are being signed, each partner must have a valid email address for eSignature. Every patient must enter their own personal email address, e.g. not a shared email with a partner.
Enter Email Confirm Email
Date of Birth*

Day
Month
Year
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Menstrual History
How many days is your menstrual cycle?*
(i.e. from start of one period to the start of next one)?
Date of last menstrual period?*
For how many days do you bleed?*
Cervical Smear
Have you ever had an abnormal smear?*
- Yes
- No
If yes, did you need treatment?*
- Yes
- No
If yes, please give details:*
Previous Fertility Treatment Details
Have you ever had fertility treatment or fertility investigations elsewhere?*
- Yes
- No
If Yes, please give brief details and forward any paperwork you may have prior to your Doctor consultation*
Previous Pregnancy Details
Please fill in any previous pregnancy details:*
Sexual History
Have you ever had problems with sexual intercourse or vaginal examinations?*
- Yes
- No
Have you ever had a sexually transmitted infection?*
- Yes
- No
Medical History
Please provide information about your medical history:*
Include surgery/operations, childhood problems medical conditions e.g. asthma infection.
Any history of bleeding disorder/ bleeding after procedures?*
- Yes
- No
If yes, please give details:*
Current medications*
Allergies to medications*
Family History
Please provide information about your family history:*
Include history of serious medical conditions which may be hereditary
Body Mass Index
Height (in cms)?*
Weight (in kgs)?*
BMI assessments will take place at our nurse consultation.
Lifestyle
Cigarettes per day*
Use 0 for non smokers
Frequency of vaping.*
Use 0 for non vapers
Average weekly alcohol intake (units)*
(I unit = ½ pint beer, 1 small glass wine. Use 0 for non drinker)
Average weekly exercise undertaken*
Do you have any significant stresses in your life?*
- Yes
- No
If Yes, please provide details*
Is there any other information you think we should know e.g. Religious/Ethical concerns?*
- Yes
- No
If Yes, please provide details*
Patient Identification*
Please upload a valid photo ID (passport, driver's license, etc.)
Drop files here or

Accepted file types: jpg, gif, png, jpeg, Max. file size: 10 MB, Max. files: 1.

Accredited by:

We are Ireland’s only not-for-profit fertility clinic with over 25 years of experience and excellent rates of success. Closely associated with the National Maternity Hospital, our highly experienced Consultants offer individualised care so you can begin and continue your journey with us.

CHKS accreditation demonstrates our commitment to delivering the highest standards of patient care.

Contact Details
60 Lower Mount Street, Dublin 2, Ireland
Reception: +353 1 556 7900
Fertility Nurse: +353 1 556 7901

Opening Hours
Mon – Fri: 8am – 4pm

* Saturday, Sunday and Bank Holidays are for patients undergoing treatment – Appointment Only.

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Privacy Policy
Cookie Policy
Terms & Conditions

Fertility Tests

Fertility Treatments

Male Factor

Donor Services

Fertility Preservation

Genetics programme

Fertility Tests

Fertility Treatments

Male Factor

Donor Services

Fertility Preservation

Genetics programme

Female Screening Form – Gynaecology

Female Screening Questionnaire (Gynaecology)

Menstrual History

Cervical Smear

Previous Fertility Treatment Details

Previous Pregnancy Details

Sexual History

Medical History

Family History

Body Mass Index

Lifestyle