Female Fertility

FEMALE FERTILITY – PATIENT HISTORY
Please fill in to the best of your ability. If you are unsure please leave it blank.
Date____________ Patient Name___________________________________

Birth_____________ Ob/Gyn name and location
_________________________________________________ Fertility Center
__________________________________________________________ Fertility Doctor
__________________________________________________________
Are you preparing for an IVF cycle? Yes / No Frozen Cycle: Yes / No Donor Cycle: Yes
/ NoSurrogate: Yes / No Estimated Retrieval Date_______________ Estimated Transfer
Date_______________
Prior IVF History (please provide date, fertility center and outcome of cycle )
1.)____________________________________________________________________
2.)_____________________________________________________________________
3.)_____________________________________________________________________
4.)_____________________________________________________________________
Prior IUI History (dates/outcome)

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Date of last period:_______________________
Problematic Diagnosis with date of diagnosis if possible:
FSH / LH_______________________________________________________________
Endometriosis___________________________________________________________
Ovaries / PCOS Fibroids___________________________________________________
Fallopian Tubes Uterine lining______________________________________________
Thyroid ________________________________________________________________
NK Assay/Immunolgy_____________________________________________________
Blood Clotting Issues ?_____________________________________________________
Partner’sSperm: Mobility_________ Morphology__________Quantity__________

Other issues of partner affecting fertility______________________________________
Patient History:How long have you been trying to conceive?____________________
Prior pregnancies (dates) ___________________________________________________
Terminated (dates) ________________________________________________________
Miscarriages (dates) _______________________________________________________
Children (date of births)____________________________________________________
Menstrual History:
Age of first period ______ Prior to fertility treatments, were your cycles regular? Y / N
Interval between periods (day between one period to the next)_________ How many
days of flow______________
Color of blood (bright red, dark, etc)______________________Clots__________
Is there spotting before your actual flow? If so, how long does it last and what color is it?
________________________________________________________________________
Do you experience PMS? If so, please describe symptoms, either emotional or physical:
________________________________________________________________________
How close to your period do experience these symptoms?_________________________
Do you ovulate?__________________________________________________________
How do you know you ovulate?______________________________________________
Do you get cervical mucus at ovulation?_______________________________________
What day of your cycle typically is ovulation?__________________________________
Other information:
Have you ever had a venereal disease? Please detail______________________________
Do you get yeast infections often?____________________________________________
Do you have herpes or sores on your genitals?___________________________________
Have you taken birth control pills in the past? Please provide
dates.__________________________________________________________________
Do you douche?_________________ Do you use lubricants?_______________________

Do you exercise regularly?_____________
If so, what do you like to do for exercise and how

often?___________________________________________________________________
________________________________________________________________________
Do you have a good outlet for stress? If so,
what?___________________________________________________________________
________________________________________________________________________
Do you feel your stress level is high?__________________________________________
What medications are you
taking?__________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
What vitamins or supplements are you
taking?__________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Do you eat a well balanced diet? Always Sometimes Occasionally Never
Do you eat breakfast? Always Sometimes Occasionally Never
Do you sleep well?____________
If no, please explain:__________________________________
How many hours on average a night?_________ Do you have nightsweats?_______
How Often?_________________ Do you smoke?_____________ How

often?___________________________________ Do you drink alcohol? ________How
often?___________________________________ Do you drink coffee?_________ How
often?____________________
Do you use recreational drugs? _______________ What?________________________

How often?_____________________________________________________________
Your Overall Health: Excellent Good Fair Poor Do you have a tendency to feel hot or
cold?_____________________________ Do you have cold hands and/or
feet?___________________________________
Any other major health issues or concerns?

_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

Female Fertility

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FEMALE FERTILITY – PATIENT HISTORY

Date____________ Patient Name___________________________________

Prior IUI History (dates/outcome)

Date of last period:_______________________

Problematic Diagnosis with date of diagnosis if possible:

Partner’sSperm: Mobility_________ Morphology__________Quantity__________

Color of blood (bright red, dark, etc)______________________Clots__________

Have you ever had a venereal disease? Please detail______________________________

Do you get yeast infections often?____________________________________________

Do you have herpes or sores on your genitals?___________________________________

Do you douche?_________________ Do you use lubricants?_______________________

If so, what do you like to do for exercise and how

Do you eat a well balanced diet? Always Sometimes Occasionally Never

Do you eat breakfast? Always Sometimes Occasionally Never

Do you sleep well?____________

If no, please explain:__________________________________

How many hours on average a night?_________ Do you have nightsweats?_______

How Often?_________________ Do you smoke?_____________ How

Do you use recreational drugs? _______________ What?________________________

Any other major health issues or concerns?

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Date Patient Name_______________________

Partner’sSperm: Mobility_ MorphologyQuantity____

Color of blood (bright red, dark, etc)____________Clots

Do you douche?_ Do you use lubricants?_______

How many hours on average a night?___ Do you have nightsweats?_

How Often?_____ Do you smoke?_ How

Do you use recreational drugs? _ What?__________