HYSTEROSALPINGOGRAM (HSG) QUESTIONNAIRE / CONSENT - XRays 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your name and date of birth in the designated fields at the top of the form.
3. Fill in the details regarding your menstrual cycle, including the first day of your last period, duration of your period, and cycle length.
4. Indicate the flow of your period by checking the appropriate boxes for light, normal, or heavy.
5. Answer questions about sexual activity since your last period and previous pregnancies, providing details as necessary.
6. Complete sections regarding any pelvic surgeries, ultrasounds, fertility drugs, and birth control history.
7. List current medications and any allergies you may have to X-ray contrast, iodine, shellfish, or medications.
8. Review the consent statement carefully before signing. Ensure you understand all implications related to the procedure.
9. Sign and date the form at the bottom. If applicable, have an authorized representative sign as well.

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