Get the free Infertility History Form - coe ucsf

Infertility History Form IMPORTANT: Please complete this form prior to your visit. This form was developed by the American Society for Reproductive Medicine and UCSF to assist physicians and patients

How to fill out infertility history form

How to fill out an infertility history form:

1. Start by carefully reading the instructions provided at the beginning of the form. These instructions will guide you on what information to include and how to fill out each section.
2. Begin with providing your personal details such as your name, contact information, and date of birth. This will help the healthcare provider to identify your form accurately.
3. The next section may ask for information about your medical history. Provide details about any previous conditions, surgeries, or medications you have taken that could be relevant to infertility.
4. The form might ask about your menstrual cycle. Note down the regularity of your periods, the length of each cycle, and any irregularities you have observed.
5. You may be asked about your sexual history, including the number of sexual partners, contraceptive methods used, and any sexually transmitted infections you have had in the past.
6. Fill in details about any previous pregnancies or pregnancies that ended in miscarriage. Include information about the outcome, duration, and any medical interventions involved.
7. The form may request information about lifestyle factors that could impact fertility. Answer questions about smoking, alcohol consumption, drug use, and exercise habits honestly.
8. Your family's medical history may be relevant, so provide details about any fertility issues, genetic conditions, or hereditary diseases that run in your family.
9. Finally, make sure to review the form for completeness and accuracy before submitting it. Take your time to ensure that all the relevant sections have been adequately filled out.

Who needs an infertility history form:

1. Individuals or couples seeking fertility treatment: If you are consulting a fertility specialist or undergoing treatments such as in vitro fertilization (IVF), the healthcare provider may require a comprehensive infertility history form to assess your condition properly.
2. Those experiencing difficulties conceiving: If you have been trying to conceive for an extended period without success, your doctor may request an infertility history form to gather relevant information about your medical history, lifestyle factors, and potential reasons for the difficulties.
3. Patients undergoing reproductive health evaluations: If you are going through an evaluation of your reproductive health, an infertility history form will aid the healthcare provider in understanding your fertility potential and identifying any underlying issues that could be affecting your ability to conceive.

Remember, filling out an infertility history form accurately and honestly can greatly assist healthcare providers in determining the appropriate course of action and tailoring treatments to your specific needs.

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What is infertility history form?

The infertility history form is a document that collects information about a person's reproductive health history.

Who is required to file infertility history form?

Individuals seeking fertility treatment or assisted reproduction are required to file an infertility history form.

How to fill out infertility history form?

The infertility history form can typically be filled out online or in person at a fertility clinic or healthcare provider's office.

What is the purpose of infertility history form?

The purpose of the infertility history form is to provide healthcare providers with important background information about a person's reproductive health, which can help guide treatment decisions.

What information must be reported on infertility history form?

Information that must be reported on the infertility history form may include medical history, previous pregnancies, and any fertility treatments or medications previously used.