Infertility Evaluation

"*" indicates required fields

Please Answer All the Questions Thoroughly and to Your Best Knowledge:

Name*

DOB*

1. How long have you been having unprotected sexual intercourse for?*

2. What contraception have you used in the past?*

3. When did you stop using contraception?*

4. Have you used lubricants during intercourse?*

5. Do you douche after intercourse?*

6. How often do you and your partner have intercourse(# of times)?*

Weekly

Monthly

Only during fertile period

7. Are your menstrual cycles regular or irregular?*

8. Do you have any medical history we should be aware of?*

9. Have you ever been pregnant in the past?*

10. Are you currently having any pelvic pain, abnormal bleeding or abdominal pain?*

11. Have you ever had fertility treatments or consults in the past?*

12. What is your partner's name?*

13. Has your partner ever conceived/fathered any children in the past?*

14. Does your partner have any past medical history we should be aware of?*

15. Does partner have any history of bicycle riding, testicular trauma or STl's?*

16. Does your partner currently take any medications?*

This field is for validation purposes and should be left unchanged.