Duration of Infertility yrs/months
Nature of present employment
Concerns regarding chemical exposure at your current employment?
If so, when
Have you gained or lost greater than 20 pounds in this past year?
Do you have a history of anorexia or bulimia?
When? For how long?
Do you have any special dietary habits or follow any particular food diet?
If yes, please specify:
Do you use any dietary aids?
Weight loss products?
Dietary supplements(including vitamins)
If yes, please specify:
Do you use any herbal or other medicinal therapies
Do you consume caffeine?
If yes, please specify amount
Do you or have you ever used:
if yes, how much per week do you consume?
if yes, amount per day
Illicit or recreational drugs (marijuana, cocaine etc.):
if yes, please specify
Do you currently exercise?
What form of exercise?
How many hours per week?
Do you or have you in the past used anabolic steroids?
If yes, when
Please list any allergies to medications, food, Iodine or X-ray dye
Do you have a history of abnormal Pap smear? Y/N When? How was it treated? Laser, Cryotherapy (freezing), LEEP, other
Do you experience acne? YesNo
Do you have or have you ever have
Cancer (hair growth on face, breast, abdomen)
High blood pressure
Condyloma (genital warts)
Vaginitis: yeast, bacteria, trichomonas
Are you immunized against
Have you had chicken pox? YesNo
Are you at risk for exposure to parvovirus, CMV, toxoplasmosis, Tuberculosis?YesNo
Have you ever had surgery for tubal reversal:YesNo
Please list any other surgeries and dates:
Are your periods regular?
What is the usual number of days from the start of one period to the start of the next period?
How many days of menstrual flow do you usually have?
Do you experience menstrual cramps?
Do you take medication for cramping? If yes, please specify
Do you bleed or spot between periods?YesNo
Do you have spotting before your period begins?YesNo
Was infertility therapy required to conceive any of your pregnancies?
Did you have complications post-partum? If yes, please specify
Do any family members have a history of infertility, endometriosis, early menopause, or
recurrent pregnancy loss? If yes, please specify
Did your mother take Diethylstilbestrol (DES) when she was pregnant with you? Y/N
What contraceptives have you used in the past?
When did you discontinue any hormonal contraceptives?
Have you ever used an IUD? Y/N If yes, when
How many times per week do you and your spouse/partner have sexual intercourse?
How many times do you have sexual intercourse around ovulation?
How do you determine when you ovulate?
Do you use lubricants? If yes, which ones do you use?
Do you douche?YesNo
List any medications that you have taken for infertility and approximate dates used
Clomiphene Citrate (Serophene, Clomid)YesNo
What prior testing/treatments, if any have you had for infertility?
Please provide other information you feel is pertinent not included in this fertility
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