Fertility Clinic New Patient Questionnaire
Patient Information
Full Name
Date of Birth
Phone Number
Email Address
Address
City
State/Province
ZIP/Postal Code
Partner Information
Partner Name
Partner Date of Birth
Partner Phone
Medical History
Medical conditions (including fertility issues)
Surgeries
Allergies
Current Medications
Menstrual & Obstetric History
Age at first period
Cycle length (days)
Are cycles regular?
Yes
No
Number of pregnancies
Number of births
Number of miscarriages
Date of last period
Fertility History
How long have you been trying to conceive?
Previous fertility treatments
Prior investigations (tests, labs, imaging)
Lifestyle
Do you smoke?
No
Yes
Quit
Do you use alcohol?
No
Yes
Caffeine intake (cups/day)
Recreational drug use
Exercise frequency
Family History
Family history of fertility problems or genetic disorders
Anything else you would like us to know?