herbal conception

A basic background to infertility in the UK, IVF treatment in the UK, what benefits can Chinese medicine bring to the infertility forum?

An open assessment of the costs for each stage of this alternative infertility treatment.

Mail order returns and refunds


Please go below this form for more information about our preliminary consultation
HERBAL CONCEPTION/CHINESE HERBAL CLINIC LTD 5 BRAME ROAD HINCKLEY LEICESTER LE10 0ET ENGLAND
Price: £7	Click to payment page



Download Printable Document Preliminary Consultation form

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YOUR CONTACT NAME & ADDRESS

Title: Mr/Mrs/Miss/other
First names:
Surname:
Flat / House name or number:
Street name:
Town:
County:
Postcode:
Country:
Phone number:
Email address:

MALE BRIEF HEALTH HISTORY

Present age
Weight
Height
Any diseases since puberty? (e.g. mumps)
Any surgery?
Do you smoke?	Yes	No	Lightly	Moderately	Heavily
Do you drink alcohol?	Yes	No	Lightly	Moderately	Heavily
Do you suffer stress?	Yes	No	Lightly	Moderately	Severe
What type of stress?	anxious	irritable		palpitations
Any relevant additional information?

FEMALE BRIEF HEALTH HISTORY

Present age
Weight
Height
Any diseases since puberty? (e.g. Chlamydia)
Any surgery?
Have you been diagnosed with a specific gynaecological problem?
Have you experienced any miscarry please give details?
Any specific information about your periods you find relevant?
Do you smoke?	Yes	No	Lightly	Moderately	Heavily
Do you suffer from stress?	Yes	No	Lightly	Moderately	Severe
What type of stress?	anxious	irritable		palpitations
Do you have children already?

INFERTILITY CASE HISTORY

How long have you been trying to conceive?
As a couple what tests have you taken?
Which partner has been found to be the cause of infertility?
What treatment have you had so far?
How long have you taken this treatment?
Any relevant additional information?
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