Get the free INFERTILITY HISTORY FORM - Sanford Health

Name: Date of Birth: Chart Number: INFERTILITY HISTORY From This form was developed by the American Society for Reproductive Medicine to assist physicians and patients in obtaining a complete infertility

How to fill out infertility history form

How to fill out infertility history form

1. Step 1: Start by gathering all relevant medical records such as previous test results, diagnoses, and treatments.
2. Step 2: Fill out the personal information section of the infertility history form, including your name, age, contact information, and any relevant medical history.
3. Step 3: Provide detailed information about your menstrual cycle, including the length of your cycle, the regularity of your periods, and any additional symptoms you experience.
4. Step 4: Answer questions related to your sexual health, including information about contraception, previous sexually transmitted infections, and any difficulties or concerns related to sexual activity.
5. Step 5: Describe any previous pregnancies or attempts at pregnancy, including the outcome of those pregnancies and any complications or difficulties experienced.
6. Step 6: Provide a detailed medical history, including information about any underlying medical conditions, surgeries, medications, or treatments you have received.
7. Step 7: Answer questions about your lifestyle and habits, including information about your diet, exercise routine, stress levels, smoking or alcohol consumption, and any exposure to environmental toxins.
8. Step 8: Review the completed form to ensure all sections are filled out accurately and completely.
9. Step 9: Sign and date the form to signify that the information provided is true and accurate.
10. Step 10: Submit the completed infertility history form to your healthcare provider or fertility specialist.

Who needs infertility history form?

1. Anyone who is seeking medical assistance or treatment for infertility may be required to fill out an infertility history form.
2. This form helps healthcare providers and fertility specialists gather important information about a patient's medical history, lifestyle, and reproductive health, which can aid in diagnosis, treatment planning, and personalized care.
3. Both men and women may be asked to fill out this form, as infertility can affect both genders.
4. It is generally recommended for individuals or couples who have been trying to conceive for a year without success, or who have known fertility issues, to complete an infertility history form.

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What is infertility history form?

The infertility history form is a document that collects information about an individual's history of infertility.

Who is required to file infertility history form?

Individuals who are seeking fertility treatments or assisted reproductive technologies may be required to file an infertility history form.

How to fill out infertility history form?

To fill out the infertility history form, individuals must provide details about their medical history, previous pregnancies, and infertility treatments.

What is the purpose of infertility history form?

The purpose of the infertility history form is to help healthcare providers understand an individual's reproductive health and make informed decisions about treatment options.

What information must be reported on infertility history form?

Information such as medical conditions, previous pregnancies, infertility treatments, and family history of infertility may need to be reported on the infertility history form.