Infertility Worksheet
Use this form to organize pertinent information. Bring it filled out and all results from prior testing with you to your appointment for infertility treatment.My Medical History:
My Surgical History:
My Partner’s Medical History:
My Partner’s Surgical History:
Menstrual History
Age at first period:
Length of periods:
Are they regular?:
How many days between cycles:
Dates of last 3 cycles:
Reproductive History
Miscarriages or Pregnancy Loss (Include the date, how far along you were, and any testing that was done):
Number of children:
Does your partner have any children?
Timing Methods
Ovulation Predictor Kits? Are you reliably detecting your surge?
Basal Body Temperature Testing?
Changes in Cervical Mucus?
How long have you been trying?
Any Prior Infertility Testing or Semen Analysis?
Questions to Ask the Doctor
1.
Answer:
2.
A:
3.
A:
4.
A:
5.
A:
Next Steps
Testing to be completed:
Dates/times for testing:
Instructions:
Next appointment:
