Fertility Treatment Medical History Form
Personal Information
First Name
Last Name
Date of Birth
Phone
Email
Address
Medical History
Known Medical Conditions
Previous Surgeries
Allergies
Current Medications
Family Medical History
Gynecological History
Age at First Period
Typical Cycle Length (days)
Menstrual Problems
History of STIs
Contraceptive History
Obstetric History
Number of Pregnancies
Live Births
Miscarriages
Details (e.g. complications, outcomes)
Fertility Treatment History
Previous Fertility Treatments
Response to Past Treatments
Diagnoses (if any)
Partner Testing/Results
Lifestyle
Smoking
No
Yes
Former
Alcohol Consumption
No
Occasionally
Regularly
Exercise (type and frequency)
Other Relevant Information