Seeking God for the fruit of the womb?

This form is divide into two parts. Part A & B. The Part A is to be filled with the concerned woman while part B is to be filled with the concerned man.

PART A.

Full Name of the woman Form A – THIS FORM IS TO BE FILLED BY THE WOMAN CONCERNED *

Address *

Valid Email Address *

State of Origin *

Nativity *

Country *

Phone number(s) *

Religion *

Profession/Job *

If Christianity, Denomination? *

If The Apostolic Church, state: Assembly, District & Area *

Have you married? *

When did you marry? *

Do you live together with your husband? *

Did you marry a married man? *

What happened to his 1st wife? *

Has the man got any child? *

If yes, when was the last issue? *

Have you ever been pregnant? *

If then, when? *

How many pregnancies have you deliberately aborted? *

What means did you apply? *

Does your menstruation regular? *

Does it black in color? *

Does it contain particles? *

Does it smell? *

Has it ever ceased without pregnancy? *

What is your age? *

Have you ever contracted with any infection, sexually transmitted disease (STD) or toilet disease? *

What is the nature of the toilet you were/are using? *

Do you have fibroid? *

Does any of your fallopian tubes block? *

Do you experience still-birth? If yes, how many? *

Do you experience miscarriage? If yes, how many and at what month? *

Is there anyone in your family or husband’s family that is barren? *

Have you undergone any surgery before? If yes; state the kind of surgery *

What are the medical tests undergone? Briefly explain: (attach photocopy) *

Briefly narrate some of your reoccurring dreams here *

State other information that could help our findings here *

Full name (Husband) Form B – THIS IS TO BE FILLED BY THE MAN CONCERNED (Go for a sperm count test, attach the copy of the test result here) *

Have you undergone sperm count test?

How did you produce the sperm: Masturbation? sexual intercourse?

If you have undergone sperm count test; state the percentage of the following

Volume

Motility

Active cells

Sluggish cells

Dead cells

Total count