Women'S Fertility History I - The Caporale Center Of Natural Health Page 3
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4CONFIDENTIAL
women’s fertility history III
NAME (LAST, FIRST, MIDDLE)
DATE
HOW LONG HAVE YOU BEEN TRYING TO CONCEIVE? ______________________________________________________________________________________________________
REPRODUCTIVE ENDOCRINOLOGIST’S NAME (IF APPLICABLE) ________________________________________________________________________________________________
WHICH OFFICE LOCATION DO YOU SEE HIM/HER AT FOR REGULAR APPOINTMENTS? ___________________________________________________________________________
YES
NO DATE
DESCRIPTION
HAVE YOU HAD A DIAGNOSIS RELATING TO INFERTILITY?
___________
___________________________________________________
HAVE YOU HAD FERTIITY TREATMENTS?
___________
___________________________________________________
HAVE YOUR FALLOPIAN TUBES BEEN MEDICALLY EVALUATED?
___________
___________________________________________________
HAVE YOU HAD ANY TUBAL OPERATIONS?
___________
___________________________________________________
HAVE YOU HAD HORMONE LABORATORY TESTS PERFORMED?
___________
___________________________________________________
HAS YOUR PARTNER HAD A FERTILITY WORKUP?
___________
___________________________________________________
DOES YOUR PARTNER HAVE A DIAGNOSIS RELATING TO INFERTILITY?
___________
___________________________________________________
DO YOU OVULATE ON YOUR OWN? (If yes, on what day of your cycle?)
___________
___________________________________________________
HAVE YOU TAKEN MEDICATION TO HELP YOU OVULATE?
___________
___________________________________________________
HAVE YOU HAD ACUPUNCTURE FOR FETILTY? (If yes, where?)
___________
___________________________________________________
Please list the results of the following below or attach copies of you lab reports to this packet.
MEDICAL EVALUATION OF FALLOPIAN TUBES
TUBAL OPERATIONS
HORMONE LABORATORY TESTS
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