Fertility History Questionnaire
Please answer the 41 questions. Then I will set up a time to meet with you.
Name *
Your answer
Email *
Your answer
Address *
Your answer
Phone number *
Your answer
What is your birthdate *
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What is your main need/ desire for your fertility journey. *
Your answer
1. At what age did you reach puberty? Years old
Your answer
2. How tall are you? feet inches
Your answer
3. How much do you weigh? Pounds
Your answer
4. Are you having trouble getting pregnant? yes no. If yes, why do you think that you are having trouble?
Your answer
5. Has anyone ever told you that you have polycystic ovarian syndrome?Yes no
Where you ever told that they thought you had endometriosis?
Your answer
6. Do you think a that you have a problem ovulating?Yes no
Your answer
7. Has your partner been tested for fertility issues?
Your answer
8. Do you have insulin resistance? yes no I don’t know
Your answer
9. Have you taken any medications to help you get pregnant? no. If yes, check the medicine that you were given(you may check more than one)
If other medicine list here.
Your answer
11. Are your menstrual cycles regular and predictable?yes no
12. If yes, approximately how often did your menstrual cycles come?(check the box that best describes most of your menstrual cycles)
13. If your periods are not regular and predictable, what is the shortest and longest interval that you have had between periods
Your answer
14. If your periods are not regular and predictable, at what age did this begin?Years old
Your answer
15. Have you ever taken medicine to regulate your menstrual cycles?Yes No
16. If yes, list them and when you took them. Ex. Birth control pills, Provera, Other (please name if you remember)
Your answer
17. As an adult have you had acne? If yes, do you have acne now?
Your answer
18. Do you have any problem with hair loss on your head?
19. Do you think that you have more hair than most women on some areas of your body?Yes No, If yes where
Your answer
20. How long have you and your present partner been trying to conceive?
Your answer
21. Have you ever been infertile with a past partner? If so, How long?
Your answer
22. Have you had any fertility tests performed on you? Please note which ones and when?
Your answer
23. How old were you when you started having periods?
Your answer
24. Date your last period started
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DD
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YYYY
25. How many days do your periods last?
Your answer
26. Do you have cramps with your periods?If yes, are they: Mild Moderate Severe
Your answer
27. Do you have pain with intercourse?
Your answer
28. What type of contraception have you used in the past?
Your answer
29. When did you last use contraception?
Your answer
30. Have you ever had an abnormal Pap smear?If so, when?
Your answer
31. Medical History Do you have or have you ever had (check all that apply)
32. Are you allergic to any medications?What?
Your answer
33. Have you ever had surgery before?Date and type
Your answer
34. What supplements are you taking now?
Your answer
35. What is your job?
Your answer
36. Do you drink alcohol? What kind? How much per week?
Your answer
37. Do you have a special exercise program?Type Number of hours per week?
Your answer
38. What does your diet look like?
Your answer
39. Are you frequently sad, crying, angry, or emotional?
Your answer
40. How do you sleep? Do you fall asleep easily and stay asleep all night?
Your answer
41. How is your energy
Your answer
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