Complete the questionnaire test and a specialist member of our Fertility team will be in touch soon.

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* 1. Full name

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* 2. Email Address

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* 3. Contact Number

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* 4. How long have you been trying to get pregnant?

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* 5. Female: Date of birth

Date / Time

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* 6. Male:  Date of birth

Date / Time

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* 7. Female: Have you had fertility treatment in the past?

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* 8. Male: Have you had fertility treatment in the past? 

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* 9. Female: Have you had any previous pregnancies?

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* 10. Female: Have you had any previous miscarriages?

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* 11. Male: Do you have any children?

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* 12. Male: Have you had any operations, injuries or infection in the testicles or groin?

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* 13. Male: Have you ever had an abnormal semen analysis? 

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* 14. Male: Do you smoke cigarettes?

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* 15. Would you be interesting in attending our next free Fertility Open Event?

Thank you for taking the time to complete this questionnaire. One of our specialists will be in touch with you soon!

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