Infertility Questionnaire

The following questionnaire is designed to help your physician evaluate your infertility. Please circle or fill in the appropriate answer. If you have any questions or additional comments write them in the space provided.

  1. General Information

O:\Forms\Clinical Care\Approved\Infertility\Infertility Questionnaire.doc Approved 3/2010

  1. Date:

Home Phone #: (______) ______

O:\Forms\Clinical Care\Approved\Infertility\Infertility Questionnaire.doc Approved 3/2010

2. Husband Name: ______SSN: ______

3. Wife Name: ______SSN: ______

4. Age: Husband: ______Wife: ______

5. Occupation: Husband: ______Wife: ______

  1. Fertility History
  1. Are your currently married?YesNo
  1. What is the duration of your current marriage? ______
  1. How long have you been attempting to initiate a pregnancy? ______
  1. Have you been involved in any previous pregnancies in this current marriage? Yes No

If yes:Age(s) ______

Gender(s) ______

Any difficulties in initiating? ______

5. Have you previously been married?YesNo

Did any pregnancies result in that marriage?YesNo

If yes:Age(s) ______

Gender(s)______

Any difficulties in initiating? ______

6. Have you been previously evaluated or treated for infertility?YesNo

If yes:When?

By whom?

What treatment was performed? ______

______

7. Has your wife been evaluated for infertility?YesNo

If yes:When?

By whom?

What tests have been performed? BBT, ultrasound, hysterosalpingogram, endometrial biopsy, post-coital test, laparoscopy

  1. Sexual History
  1. Do you have any problems with erection? YesNo

If yes: initiation, rigidity, curvature, duration, premature ejaculation

2. Any lubricants used during intercourse? YesNo

If yes, what kind?

3. Are you timing intercourse with ovulation?YesNo

4. How frequently do you have intercourse? ______

  1. Childhood
  1. At what age was the onset of puberty?
  1. As a child did you have:

a)Undescended testiclesYesNo

If yes, what side?RightLeft

b)Testicular torsionYesNo

c)Hernia surgeryYesNo

d)MumpsYesNo

If yes, did involve testicles?YesNo

Did it occur after puberty?YesNo

e)Bladder surgeryYesNo

f)Hypospadias surgeryYesNo

  1. Medical History
  1. Do you have any medical problems?YesNo

If yes, what are they? ______

______

2. Do you take any medication?YesNo

If yes, what are they?______

3. Are you allergic to any medications?YesNo

If yes, what are they?______

______

  1. Surgical History
  1. Have you had any previous operations?YesNo

If yes, what was performed?______

______

  1. Infections
  1. Have you had any previous infections of the following-

(If yes, please list dates and describe treatment below)

a)KidneysYesNo

b)ProstateYesNo

c)TesticlesYesNo

d)EpididymisYesNo

e)UrethraYesNo

  1. Exposure
  1. Have you had any exposure in the last six months to-

a)PesticidesYesNo

b)ChemotherapyYesNo

c)Anabolic SteroidsYesNo

d)High TemperaturesYesNo

e)X-RaysYesNo

  1. Social History
  1. Do you consume alcohol?YesNo

If yes, how much per week? ______

  1. Do you presently smoke or have you ever smoked:

a)CigarettesYesNo

Amount per day

b)MarijuanaYesNo

Amount per day

  1. Family History
  1. Does anyone in your family have a history of-

(Please state your relationship with that person as well)

a)InfertilityYesNo

Relationship______

b)Cystic FibrosisYesNo

Relationship______

c)Hormonal ImbalanceYesNo

Relationship______

  1. Current Personal Problems
  1. Do you, or have you had problems with:

a)Chronic Respiratory InfectionYesNo

b)Loss of sense of smellYesNo

O:\Forms\Clinical Care\Approved\Infertility\Infertility Questionnaire.doc Approved 3/2010