Transgender Screening Questionnaire

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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 County Eircode Country
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 details regarding previous children (including with other partners)*
Medical History
Please provide information about your medical history:*
Include surgery/operations, childhood problems medical conditions e.g. asthma infection.
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.

Printable Forms

Referrals can be sent by Post to:
Merrion Fertility Clinic,
60 Lower Mount St,
Dublin 2

Referrals can be sent by email to:
info@merrionfertility.ie

Fertility Tests

Fertility Treatments

Donor Services

Fertility Preservation

Wellbeing

Genetics programme

Fertility Tests

Fertility Treatments

Donor Services

Fertility Preservation

Wellbeing

Genetics programme

Transgender Screening Questionnaire

Previous Fertility Treatment Details

Previous Pregnancy Details

Medical History

Family History

Body Mass Index

Lifestyle

Printable Forms

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