Reproductive Health & Fertility History
Please take time to thoughtfully and honestly answer these questions so we're able to develop an individualized diagnosis and treatment plan that's right for you.
Female Patient Name:
Date of Birth:
-
Month
-
Day
Year
Date
What are your expectations for this visit?
How many months have you been having intercourse without any form of birth control?
Menstruation history:
What is your menstrual cycle pattern? (Check all that apply)
Regular
Irregular
Spotting before period
Spotting Color: Pink
Spotting Color: Red
Spotting Color: Brown
Spotting after period
Spotting Color: Pink
Spotting Color : Red
Spotting Color : Brown
Bleeding between periods
Light/Heavy periods
Period lasts less than 3 days
Period lasts more than 10 days
No periods
When did you stop having them?
How many days are between periods?
How many days of bleeding do you have?
List the dates of 1st day of your last two menstrual periods:
How many periods do you have a year?
Do you need medication to bring on a period? Y / N
Y
N
If yes, what type?
Pregnancy summary:
Total number of ALL pregnancies:
How many children have you had?
Number of miscarriages (< 20 wks):
Number of abortions:
Number of full-term deliveries:
Number of premature (< 37 weeks) deliveries:
Pregnancy summary:
Rows
Date pregnancy ended or delivered
Months to conception
Treatments to conceive
Delivery type - D&C complications
Current partner? (Y/N)
1
2
3
4
5
Contraceptive and sexual history:
Contraceptive and sexual history:
None
Condoms
Injectable contraception
Birth control pill
Name of Contraceptive Pill:
Contraceptive and sexual history (continued):
Pill / Continuous use (no monthly bleeding)
Pill / Monthly withdrawal bleeding
IUD Copper
IUD Hormonal
NuvaRing
Diaphragm
Never used birth control pills
Other forms of birth control:
Please list the dates of use for each form of contraception you've used:
Please list any complications:
Are you sexually active?
Yes
No
How many times do you have intercourse per week?
None
Have you used over the counter ovulation kits to time intercourse?
Yes
No
Unable to get LH Surge Positive
Are you using a wearable device? If so, what kind?
Are you using any other tracking technology? If so, what kind?
Do you have pain with intercourse?
Yes
No
Use lubricants (K-Y Jelly, etc) during intercourse
Yes
No
Have you ever had an abnormal pap smear?
Yes
No
If yes, when:
Have you ever had a cervical biopsy?
Yes
No
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Next
Have you ever been diagnosed with a chlamydial infection?
Yes
No
If yes, when:
Do you have any history of sores on your genitalia?
Yes
No
Have you ever had pelvic inflammatory disease (PHD)?
Yes
No
If yes, were you treated for it?
Yes
No
Have you ever been diagnosed with uterine fibroids or polyps?
Yes
No,
If yes when / what treatment?
Have you ever been diagnosed with endometriosis?
Yes
No,
If yes when / what treatment?
Have you ever been diagnosed with pelvic adhesions?
Yes
No,
If yes when / what treatment?
Have you ever been diagnosed with any pelvic abnormalities?
Yes
No,
If yes when / what treatment?
Have you had any prior infertility testing or/and treatment?
Yes
No
What clinic have you been seen at?
Name of Physician / R.E. / OBGYN / Midwife:
What is your infertility Diagnosis?
Prior Tests (check all that apply)
Basel body temperature chart
Yes
Date & Results:
Bring your BBT Charts to 1st Visit!
Are you tracking BBT using an app?
Yes
If so, which app?
Day 3 Blood test for FSH
Yes
Date & Results:
Thyroid test
Yes
Date & Results:
Progesterone blood test
Yes
Date & Results
Prolactin blood test
Yes
Date & Results:
Hysterosalpingogram (HSG)
Yes
Date & Results:
Hysteroscopy surgery
Yes
Date & Results:
Laparoscopy surgery
Yes
Date & Results:
Prior Treatment (Fill in all that apply)
Prior Treatment (Fill in all that apply)
Rows
# of Cycles
Date From / To
Outcome:
Intrauterine Insemination (IUI)
Delivered
Ectopic
Miscarriage
No Pregnancy
Clomid with Time Intercourse
Delivered
Ectopic
Miscarriage
No Pregnancy
Clomid with Insemination (IUI)
Delivered
Ectopic
Miscarriage
No Pregnancy
Daily Fertility Drug Injections with (IUI)
Delivered
Ectopic
Miscarriage
No Pregnancy
Canceled IVF Attempt(s)
Delivered
Ectopic
Miscarriage
No Pregnancy
Number of Completed IVF Cycles
Please detail each completed IVF Cycle:
Rows
# of Eggs
# of Embryos Transferred
# of Embryos Frozen
Outcome
Date From / To
Cycle 1
1
2
3
4
5
6
7
8
9
10
1
2
3
4
5
6
7
8
9
10
1
2
3
4
5
6
7
8
9
10
Delivered
Ectopic
Miscarriage
No Pregnancy
Cycle 2
1
2
3
4
5
6
7
8
9
10
1
2
3
4
5
6
7
8
9
10
1
2
3
4
5
6
7
8
9
10
Delivered
Ectopic
Miscarriage
No Pregnancy
Cycle 3
1
2
3
4
5
6
7
8
9
10
1
2
3
4
5
6
7
8
9
10
1
2
3
4
5
6
7
8
9
10
Delivered
Ectopic
Miscarriage
No Pregnancy
Cycle 4
1
2
3
4
5
6
7
8
9
10
1
2
3
4
5
6
7
8
9
10
1
2
3
4
5
6
7
8
9
10
Delivered
Ectopic
Miscarriage
No Pregnancy
Number of Frozen Embryo Transfers
Please detail any frozen embryo transfers:
Rows
# of Embryos Transferred
Outcome
Date From / To
Cycle 1
1
2
3
4
5
6
7
8
9
10
Delivered
Ectopic
Miscarriage
No Pregnancy
Cycle 2
1
2
3
4
5
6
7
8
9
10
Delivered
Ectopic
Miscarriage
No Pregnancy
Cycle 3
1
2
3
4
5
6
7
8
9
10
Delivered
Ectopic
Miscarriage
No Pregnancy
Any other prior treatments? Please describe:
Is your partner supportive of your wish to conceive?
Yes
No
Is your partner supportive of your infertility treatments?
Yes
No
Please describe:
On a scale of 1-10 (10=worst), estimate the level of stress you feel due to infertility:
Describe any emotional, marital or sexual problems caused by your infertility:
Do you have a future IUI or IVF procedure scheduled?
Yes
No;
If yes, list the dates:
Last day of Birth Control Pill
-
Month
-
Day
Year
Date
First day of Stimulation Medication
-
Month
-
Day
Year
Date
Date (the week) of IUI
-
Month
-
Day
Year
Date
Date (the week) of IVF retrieval:
-
Month
-
Day
Year
Date
Date (the week) of Frozen Embryo Transfer (FET)
-
Month
-
Day
Year
Date
Do you have any other comments?
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Next
Male Patient (Partner) Name:
Date of Birth:
Have you ever seen an Urologist for evaluation?
Yes
No
If yes, when?
Physician Name:
Have you had a semen analysis?
Yes
No
Please list recently results
Rows
Volume
Count
Motility
Morphology
Comments
1.
2.
3.
Have you ever fathered any prior pregnancies?
Yes
No
Outcome of previously fathered pregnancies:
Please Select
Delivered
Ectopic
Miscarriage
How would you define your sexual energy?
Below Normal
Normal
High
Do (or did) you have an undescended testicle?
Yes
No
Have you ever been diagnosed with a varicocele?
Yes
No
Have you ever had any urologic surgeries?
Yes
No
Have you experienced erectile dysfunction?
Yes
No
Have you had exposure to any known environmental toxins or hormones?
Yes
No
Do you regularly experience nocturnal emission?
Yes
No
Do you have high cholesterol?
Yes
No
Have you ever had a spinal injury?
Yes
No
Have you experienced a high fever in the last 6 months?
Yes
No
Do you currently have any prostate conditions?
Yes
No
Have you had your testosterone levels checked?
Yes
No
Have you ever taken testosterone supplements/drugs?
Yes
No
If you answered 'Yes' to any of the above, please elaborate:
Do you smoke or vape?
Yes
No
How many / how much a day?
How many years?
Did you quit? If so, when?
Do you drink?
Yes
No
How many drinks per week?
Have you casually used marijuana, cocaine, or any similar drug?
Yes
No
Describe:
Have any of your immediate family members had difficulty conceiving a child?
Yes
No
If yes, Describe:
On a scale of 1-10 (10 = worst), estimate the level of stress you feel due to infertility:
Due to work:
List your current medical problem(s):
List your current medications:
List your current herbs, vitamins or health store supplements:
Do you have any other comments?
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