Fertility Assessment Questionnaire
Full Name
Age
Gender
Female
Male
Other
Marital Status
Married
Single
Partnered
Other
Duration Trying to Conceive (months)
Length of Menstrual Cycle (days)
Do you have irregular periods?
Yes
No
Previous Pregnancies
None
One
Multiple
History of Miscarriages
Yes
No
Relevant Medical Conditions
Current Medications
Lifestyle Factors (e.g. smoking, alcohol, exercise)
Other Notes or Concerns