Fertility Specialist Intake Questionnaire
Personal Information
Full Name
Date of Birth
Phone Number
Email Address
Partner's Name (if applicable)
Reproductive History
Years attempting to conceive
Number of pregnancies
Number of live births
Previous fertility treatments
Medical History
Current medications
Medical conditions
Allergies
Family history of infertility
Menstrual History
Age at first period
Cycle length (days)
Regularity of cycles
Regular
Irregular
Painful periods
Yes
No
Lifestyle
Smoking
Never
Former
Current
Alcohol use
Exercise frequency
Dietary habits
Concerns/Goals
Please share your main concerns or goals for this visit