the fertility connection  

Printing this page and completing it prior to your appointment saves lots of time and helps to fine-tune your treatment. All information is completely confidential and NEVER shared with anyone.

Name___________________________

Address_________________________

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Home phone_____________________

Cell___________________________ 

Email___________________________

Date____________________________

Date of Birth___________________________________

Emergency contact ______________________________

Last Day 3 FSH and AMH___________

Last TSH___________________________

Which day of your cycle was the TSH drawn__________________________

Have you had a complete thyroid panel with antibodies_______________________

If so please list results or bring a copy.

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Do you have regular menstrual cycles _______________________________

If not, how often are they _____________________________

What medications do you take regularly _______________________________

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What meds do you use occasionally_______________________________

_______________________________ List any diagnostic fertility tests you have had & the results eg. laparoscopy, HSG, Clomid challenge________________  _______________________________

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Do you know what your peak-plus-7 progesterone usually is_________________

Do you know which day of your cycle you ovulate on__________________________

How do you monitor ovulation____________

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Do you notice that you have good cervical mucus before and during ovulation__________________________

Which days have the best mucus___________ Do you chart your basal temperatures_______

Please make copies of recent charts if possible

What infertility diagnosis have you received________________________ _______________________________

What kind of sperm tests has your partner had / where was test done____________

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What were the results______________

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How old is the male partner__________

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Health problems of male partner_______

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What meds does the male use regularly / occasionally_____________________

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What is the alcohol / tobacco use of male partner_________________________

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List the dates and gestational length of any miscarriages / stillbirths & cause if known__________________________

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Have you had blood tests for miscarriage risks eg. ANA, APA, MTHFR, Protein C, Protein S? If so please bring copies.

Please list all allergies that you have___________________________ _______________________________

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List all surgeries you have had and approximate dates________________ _______________________________

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List all serious illnesses and approx. dates___________________________

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Do you easily gain weight?_______________________________

Do you find it hard to lose weight?_______________________________

Do you have low body fat?___________

How much  how often do you work out / exercise_________________________

How often / how much caffeine do you consume________________________

How often / how much alcohol do you consume________________________

Are there any auto-immune diseases in your family eg. MS, Lupus, Hashimotos, Rheumatoid Arthritis_______________

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Are there any blood clotting disorders in your family______________________

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Is there a history of infertility or miscarriage in your family_________________________

Rate the following symptoms from 0 - 3       3=very intense/frequent symptom 0=zero

Menstrual cramps                                     0 1 2 3

Clotting of menses                                    0 1 2 3

Pre-menstral syndrome                             0 1 2 3

Heavy menses                                           0 1 2 3

Very light & short menses                        0 1 2 3

Do you feel tired on waking                     0 1 2 3

Tire easily through the day                       0 1 2 3

Do you sleep poorly                                 0 1 2 3 

Do you find it hard to get to sleep            0 1 2 3 

Do you wake frequently at night              0 1 2 3 

Do you feel cold often                               0 1 2 3

Do you have cold extremeties                   0 1 2 3

Do you feel hot often                                0 1 2 3

Do you have night sweats                         0 1 2 3

Do you have headaches                             0 1 2 3

Do you have migraines                             0 1 2 3

Do you have irritable bowel                      0 1 2 3

Do you easily get constipated                   0 1 2 3

Do you have a loose stool                         0 1 2 3

Do you have indigestion                           0 1 2 3

Do you ever have vaginitis                      0 1 2 3 

Do you have yeast infections                   0 1 2 3

Do you crave sugar                                  0 1 2 3

Do you feel stressed a lot                         0 1 2 3

Do you feel easily overwhelmed              0 1 2 3

Do you feel tense frequently                     0 1 2 3

Do you feel tearful frequently                   0 1 2 3

Premenstrual syndrome                             0 1 2 3

Have you been anemic                             0 1 2 3 

What kind of PMS symptoms do you have______________________

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What do you do to relax and unwind________

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What kind of work-out / exercise do you do and how often__________________________

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How were your pregnancies______________

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How were your childbirths_________________________

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Did you conceive your prior children easily / naturally / with IVF___________________

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If you have had previous IVF cycles please make note of the following:

1.The dose of meds you took and the kind  of medication, eg. Follistim, lupron____________________________

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3. How many eggs were retrieved__________

4. How many eggs fertilized______________

5. What grade embryos were @ transfer______

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6.What day transfer was eg. day 3, 4 or 5

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7. How thick was your lining _____________

8. Was your transfer difficult or easy? Were you very crampy________________________

Note any periods of time that you have used contraceptive pills____________________

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Have you had prior exposure to or treatment for Chlamidya__________________________

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Have you had your appendix removed_______

Do you use vaginal lubricants other than PreSeed, canola oil or other sperm friendly product____________________________

Add any other notes below or on a separate paper, thank you. 

If you have had more than one IVF cycle please attach a separate paper with the same details. Thanks________________

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Please briefly note your medical history ________________________________

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 Please list any nutritional supplements and medications that you take below_________

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If you have questions about this form please feel welcome to contact us