INFERTILITY

INFERTILITY

PATIENT QUESTIONNAIRE (Version 06.08.23)
Name:

First NameLast Name
Date of Birth:

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
1. How long have you and your partner been attempting to conceive?
2. How many biological children do you have?
3. What is the age of your current partner with who you are trying to achieve pregnancy?
4. How many biological children does your partner have?
5. Has your partner been evaluated for infertility?
6. Have you ever? Check all that apply
7. Are you and your partner currently seeing a reproductive endocrinologist?
If your answer to question #7 is YES, then please move on to question #8.

If NO, then move straight to question #9.
8. Who is your reproductive endocrinologist?
9. Have you ever received treatment for infertility?
If your answer to question #9 is Yes continue to Q10.

If No, end survey.
10.What treatments have you tried for male infertility? (Select all that apply)
Patient or Representative Signature
Date

MonthDayYear
Date
Should be Empty: