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australian journal of advanced nursing

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Section 2 – Factors that may influence chance <strong>of</strong> becoming pregnant<br />

SCHOLARLY PAPER<br />

Do the following influence the chance <strong>of</strong> becoming pregnant? Rate from 1‑10 (1= not very influential 10= highly influential)<br />

Fitness<br />

Being physically fit – 1 2 3 4 5 6 7 8 9<br />

10<br />

Why? How?<br />

How <strong>of</strong>ten do you exercise and for how long? Are you physically fit?<br />

Diet<br />

Diet – 1 2 3 4 5 6 7 8 9 10 Why? How?<br />

Do you eat a healthy diet? How <strong>of</strong>ten do you eat take away food? What type?<br />

Vitamin supplements<br />

OTC Vitamins – 1 2 3 4 5 6 7 8 9 10 Why? How?<br />

Are you taking any vitamin supplements?<br />

What are you taking and why?<br />

Other OTC<br />

Are you taking any other ‘natural’ medicines or supplements?<br />

What are you taking and why?<br />

Caffeine<br />

Caffeine – 1 2 3 4 5 6 7 8 9 10 Why? How?<br />

How much c<strong>of</strong>fee/tea do you usually drink?<br />

Alcohol<br />

Alcohol – 1 2 3 4 5 6 7 8 9 10 Why? How?<br />

How much alcohol do you usually drink?<br />

Psychological stress<br />

Stress – 1 2 3 4 5 6 7 8 9 10 Why? How?<br />

Do you feel psychologically stressed?<br />

Recreational drugs<br />

Drugs – 1 2 3 4 5 6 7 8 9 10 Why? How?<br />

Do you take recreational drugs? ‑ What? How <strong>of</strong>ten?<br />

Section 3 – Making lifestyle changes<br />

Would you like to make any changes to your lifestyle?<br />

If yes what would you like to change and why?<br />

What would help you to make any change/changes?<br />

AUSTRALIAN JOURNAL OF ADVANCED NURSING Volume 26 Number 4 86

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