Forms & Questionnaires

From here you can download and print the various forms and questionnaires in connection with the foresight fertility programme. Forms should be printed, filled out and sent to: Foresight Preconception, 3 Lower Queens Road, Clevedon, North Somerset, BS21 6LX.

Instructions for Collection of Hair Samples

If the hair has been bleached or permed, none of the treated hair should be included in the sample for analysis. If the treatment has been carried out recently, a period of 12 weeks should be allowed to elapse before sampling. Hair should be cut from the back of the head, or nape of the neck, as close to the scalp as possible. At least 0.5gm of hair is required, which is about one heaped tablespoonfull. Only hair up to 1.5 inches (4cm) from the scalp can be used. If it is not possible to get a sample of hair from the head, pubic hair can be analysed. Place the hair sample(s) in a plain paper envelope, seal and label clearly with your name and Foresight reference number if you have one (this will only be the case if you have tested with us before). If sending more than one hair sample, keep them in separate sealed envelope, and clearly identify each one.

Foresight Membership Form

This form is for becoming a Foresight member,
(A4 x 2 pages)
View / Print »

Preconception Questionnaire

The Preconception questionnaire is only for couples wishing to have a baby.
View / Print »

Hair Sample Form

This form is for submitting hair samples for analysis.
(A4 x 1 page)
View / Print »

Hair Re-test Form

This form is for submitting hair samples for a re-test.
(A4 x 1 page)
View / Print »

Child Hair Sample Form

This form is for submitting hair samples for children up to and including 16 years old.
(A4 x 1 page)
View / Print »

Child Hair Re-test Form

This form is for submitting hair samples for a re-test for children up to and including 16 years old.
(A4 x 1 page)
View / Print »

Adult Female Health Questionnaire

This form is for female health only, Not for planning a baby.
(A4 x 2 pages)
View / Print »

Adult Male Health Questionnaire

This form is for male health only, Not for planning a baby.
(A4 x 2 pages)
View / Print »

Child Questionnaire

Up to and including 16 year olds.
(A4 x 2 pages)

View / Print »