Fertility History And Information Form Page 2
ADVERTISEMENT
1
2
3PRIOR INFERTILITY TESTING AND TREATMENT
(Prior to your initial visit, please fill out “ACM Center Medical Records Release Form” and send to your Doctor’s office. We also request you bring any copies of
lab. Testing/Diagnosis reports)
Have you had prior infertility testing or /and treatments? ___Yes ___No; What is your infertility Diagnosis? ______________________________
Prior Tests (check all that apply)
st
___Basal body temperature chart (date_________/results______________________________, bring your BBT Charts @ 1
visit)
___Thyroid test (date___________/results__________)
___Day 3 Blood test for FSH (date___________/results__________)
___Progesterone blood test (date___________/results__________)
___Prolactin blood test (date___________/results__________)
___Hysterosalpingogram (HSG) (date___________/results__________)
Hysteroscopy surgery (date___________/results__________)
___Laparoscopysurgery (date___________/results__________)
Prior Treatment (check all that apply)
Treatment Type
# of
Date
Outcome
cycles
From (mo/yr) to
(mo/yr)
___Intrauterine insemination (IUI)
to
___Pregnant:
; ___No pregnant
Delivered/ Ectopic/ Miscarriage
___Clomid with time intercourse
to
___Pregnant:
; ___No pregnant
Delivered/ Ectopic/ Miscarriage
___Clomid with insemination (IUI)
to
___Pregnant:
; ___No pregnant
Delivered/ Ectopic/ Miscarriage
___Daily fertility drug injection with IUI
to
___Pregnant:
; ___No pregnant
Delivered/ Ectopic/ Miscarriage
___Completed in vitro fertilization (IVF) cycle(s)
1. # eggs ____; #embryos transferred____; #frozen____
_______/_______
___Pregnant:
; ___No pregnant
Delivered/ Ectopic/ Miscarriage
2. # eggs ____; #embryos transferred____; #frozen____
_______/_______
___Pregnant:
; ___No pregnant
Delivered/ Ectopic/ Miscarriage
3. # eggs ____; #embryos transferred____; #frozen____
_______/_______
___Pregnant:
; ___No pregnant
Delivered/ Ectopic/ Miscarriage
4. # eggs ____; #embryos transferred____; #frozen____
_______/_______
___Pregnant:
; ___No pregnant
Delivered/ Ectopic/ Miscarriage
___Frozen embryo transfers
1. # embryo transferred_____
_______/_______
___Pregnant:
; ___No pregnant
Delivered/ Ectopic/ Miscarriage
2. # embryo transferred_____
_______/_______
___Pregnant:
; ___No pregnant
Delivered/ Ectopic/ Miscarriage
3. # embryo transferred_____
_______/_______
___Pregnant:
; ___No pregnant
Delivered/ Ectopic/ Miscarriage
___Canceled IVF attempt(s)
___Any other prior treatment (describe):
Is your partner supportive of your wish to conceive? ___Yes ___No
Is your partner supportive of your infertility treatments? ___Yes ___No; describe:__________________________________________________
On a scale of 1-10 (10=worst), estimate the level of stress you feel due to infertility. ________
Describe any emotional, marital or sexual problems caused be your infertility._________________________________________________________
_______________________________________________________________________________________________________________________
Do you have a future IUI or IVF procedure scheduled? ___Yes ___No; If yes, please list the dates.
Last day of Birth Control Pill ______/_______/_______
First day of Stimulation Medication ______/______/________
Date (the week) of IUI __________________
Date (the week) of IVF retrieval ______/______/________
Date (the week) of Frozen Embryo Transfer (FET) _________________________
Do you have any other comments? ________________________________________________________________________________________
______________________________________________________________________________________________________________________
Signature_______________________________________
Date ___________________________
2
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical