Patient Questionnaire - Women amp Infants39 Fertility Center 2026

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The document is an infertility questionnaire from the Women & Infants Hospital's Center for Reproduction and Infertility. It is designed for outpatient use, requiring patients to provide personal, medical, and reproductive history information. The form includes sections on health status, menstrual history, gynecologic history, obstetrical history, prior fertility testing, past medical history, family history, partner's history, review of systems, and background information related to genetic conditions. The purpose of the questionnaire is to gather comprehensive data to assist in diagnosing and treating infertility.

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Click ‘Get Form’ to open it in the editor.
Begin by entering your identifying information, including your name, date of birth, and contact numbers. This section is crucial for establishing your profile.
Proceed to the health status section. Here, you will indicate any allergies and current medications. Be thorough to ensure accurate medical assessments.
In the menstrual history section, provide details about your menstrual cycle. This information helps healthcare providers understand your reproductive health better.
Continue with the gynecologic history and obstetrical history sections. Answer all questions honestly to give a complete picture of your health background.
Finally, review all entries for accuracy before submitting the form. Use our platform's features to save or print a copy for your records.

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Versions	Form popularity	Fillable & printable
2014	4.8 Satisfied (221 Votes)

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How do you evaluate a womans fertility?

Fertility tests might include: Ovulation testing. An at-home, over-the-counter ovulation prediction kit detects the surge in luteinizing hormone (LH) that occurs before ovulation. A blood test for progesterone a hormone produced after ovulation can also document that youre ovulating.

How do they assess fertility in women?

Also known as anti-mullerian hormone (AMH), this test combines fertility blood tests with a transvaginal ultrasound. This measures your antral follicle count (AFC) and the AMH hormone produced by your ovaries, which tells your provider whether you have a typical egg count compared to other people your age.

What to ask during a fertility appointment?

Questions About Fertility Care Options What tests do you recommend for myself and my partner? How long will it take to docHub a diagnosis? What are my chances of getting pregnant? What types of fertility treatments do you offer? What is your approach to creating a treatment plan?

What to expect during a fertility test?

A doctor will put dye in your , and then use an X-ray machine to watch the dye move through your and fallopian tubes. In some cases, infertility testing may include minor surgeries to look inside your body. The doctor will use special tools to check your fallopian tubes, ovaries, and for problems.

What questions are asked during a fertility assessment?

Frequently Asked Questions Expand All What is an infertility evaluation? When should I consider having an infertility evaluation? What type of doctor does an infertility evaluation? What causes infertility? How does age affect fertility? How can lifestyle affect fertility? How can health conditions affect fertility?

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