Female History Infertility Questionnaire
*Name
*E-mail Address
Home Phone
Work Phone
Cell Phone
Age
Age of Partner
Please list any previous infertility related problems you have been diagnosed with in the past, if any.

Other (please specify):
Please identify which of the following you would like to be seen for:
Who referred you to our practice today?
Where did you hear about the Shore Institute for Reproductive Medicine?
What is your specific reason for being seen by our offices?
How long have you been trying to conceive?
Does infertility run in your family? If yes, indicate who.


Which tests below have been performed, if any?
Please indicate date and where.
Basal body temperature charts
Blood Hormone Tests
Semen Analysis
Hysterosalpingogram (HSG)
Laparoscopy
Hysteroscopy
Postcoital Tests


Have you ever been diagnosed with the following?
If yes, please indicate when.
Polycystic ovarian disease
Endometriosis
Pelvic Infection (PID) with block tubes
Pelvic Adhesions
Uterine Fibroids
Recurrent Pregnancy Loss
Problem with ovulation
Amenorrhea (no period)
Abnormal shape of uterus
Hirsutism (male pattern hair growth)
Premature Ovarian Failure
Ectopic Pregnancy
Other

Do you have both tubes and ovaries?
Has your partner ever fathered a child before?

Previous Infertility Treatments (please give details)
Clomid (Give dose, number of cycles taken, and when)
HMG (Fertility injections-Pergonal, Humegon, Repronex, Gonal F, etc. Please record drug, number of cycles, and when)
Ever had an insemination? How many and when?
Previous In Vitro Fertilization? If yes, when and where.

Please list any specific questions/concerns that you would like Dr. Morgan to address during your visit in the space provided.
  


475 Route 70 West
Lakewood, NJ 08701
Phone: 732.363.4777

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