Full Name
E-Mail
FEMALE FERTILITY MEDICAL QUESTIONNAIRE
Address
Partner's Full Name
City
State
Zip
Country
Phone # (if none, put none)
Date of Birth
Age
Procedure(s) Requested
Height
Gender
Weight
Date of Last Menstrual Period
Have you ever been pregnant?
How many children do you have?
Do you smoke?
Current medical herbs and supplements
Please Check all that apply in both columns:
Abnormal Cramping
Abnormal Pap Smear
Addiction to alcohol or drugs
Arthritis
Autoimmune
Asthma/Breathing Problems
Birth Control Pills
Bleeding Problems / Blood Clots
Blood Disorders
Cancer
Cardiac Arrhythmia (rapid heart rate)
Chronic Pancreatitis
Cirrhosis of the Liver
C-Section Pregnancy/Delivery
Exposure to Tuberculosis
Extrauterine Pregnancies
Gallstones
Gastro Issues (Crohn's, Ulcerative Colitis, etc.)
GERD (acid reflux)
Gynecological Problems
Heart Murmur
Hepatitis
Heart or Vascular disease
Hernia
High Blood Pressure, Coronary Artery Disease or Circulatory conditions
HIV or AIDS
Hormone Replacements
Hypertension/ High Blood Pressure
Hysterectomy
Incontinence (Bladder/Bowel)
Kidney Disease
Metabolic Conditions. (i.e. hypothyroidism)
Menstrual Disorders (heavy/painful/absence of periods or post mentrual)
Miscarriage(s)
Ovarian Cysts
Psychological or Social disorders
Previous reactions to Anesthesia
Seizures or Epilepsy
Sleep Apnea
Sexually Transmitted Disease
Stroke
Thromboembolism
Type 2 Diabetes
Unusual Stress
Uterus Fibroids/Tumors
Do you have any medical condition that you have been told would disqualify you for any type of medical procedure or surgery?
Do you have special needs that need accommodation? (dietary, sensory, handicap, etc)
Do you have any other medical condition that you are aware of that is not listed above?
If you checked or said yes to any above, please explain
Please explain any fertility issues that you are aware of?
Your Medical Provider
Provider Contact #
Do we have permission to contact?
Please list all previous surgeries or hospitalizations
Please list all allergies
How did you hear about us?
Chronic, Long term Steriods (past or present)
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