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Has the male partner had a semen analysis

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Partner’s Age

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Number of prior pregnancies

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Number of early pregnancy losses (miscarriages/chemical pregnancies)

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Number of tubal (ectopic) pregnancies

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How long have you been trying to conceive?

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Are your periods regular?

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Are your periods extremely painful

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Do you bleed heavily with menstruation?

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Do you have pain with intercourse?

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Do you have pain with ovulation?

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Have you undergone a Hysterosalpingogram (HSG)?

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When? (Year)

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Have you undergone a laparoscopy (via puncture sites in abdominal wall)?

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When? (Year)

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Have you undergone a laparotomy (abdominal incision)?

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Do you currently have US Insurance (If not no worries! Insurance is optional. Just continue after pressing no)

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When? (Year)