This questionnaire is designed to gather essential information about a couple’s medical history, lifestyle, and fertility concerns. It will help your HealthCoach assess your situation and recommend appropriate fertility treatments.
Personal Information
- Name:
- Date of Birth:
- Address:
- Phone Number:
- Email Address:
- Insurance Information:
Partner’s Information
- Name:
- Date of Birth:
Medical History
- General Health:
- Any chronic illnesses (diabetes, heart disease, thyroid disorders, etc.)?
- Any recent surgeries or hospitalizations?
- Any allergies or medication sensitivities?
- Current medications (prescription and over-the-counter)?
- Reproductive History:
- Age at first menstruation:
- Regularity of menstrual cycle:
- Average cycle length:
- Number of previous pregnancies:
- Number of live births:
- Any miscarriages or stillbirths?
- Any history of pelvic inflammatory disease (PID)?
- Any history of endometriosis or uterine fibroids?
- Sexual History:
- Duration of current relationship:
- Frequency of intercourse:
- Use of contraception:
- Any history of sexually transmitted infections (STIs)?
Lifestyle Factors
- Smoking: Current smoker? Past smoker?
- Alcohol Consumption: How often do you drink alcohol?
- Drug Use: Do you use any recreational drugs?
- Caffeine Intake: How many cups of coffee or tea do you drink per day?
- Diet: Please describe your typical diet.
- Exercise: How often do you exercise? What type of exercise do you do?
- Occupation: What is your occupation?
- Stress Levels: How would you rate your stress level?
Fertility Concerns
- How long have you been trying to conceive?
- Have you had any previous fertility treatments? If yes, please specify.
- Have you had any fertility tests, such as semen analysis or ovulation testing? If yes, please provide results.
- Are there any specific concerns or questions you would like to discuss with your doctor?
Please note that this is a general questionnaire and may not cover all relevant information. Your HealthCoach may ask additional questions based on your specific circumstances.
Remember to be honest and open with your HealthCoach to ensure the best possible care.