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AMERICAN SOCIETY FOR REPRODUCTIVE MEDICINE Infertility History Form FOR OFFICE USE ONLY IMPORTANT: Please complete this form and bring it with you to your scheduled visit. This form was developed

How to fill out infertility history form

How to Fill Out Infertility History Form:

1. Begin by carefully reading the instructions provided on the form. Make sure you understand all the questions and sections.
2. Start by providing your personal information, such as your name, contact details, and date of birth. It is crucial to provide accurate and up-to-date information.
3. Next, fill out the section regarding your medical history. This may include questions about any previous surgeries, existing medical conditions, or chronic illnesses you may have. Be as detailed as possible to provide a comprehensive overview of your medical background.
4. If applicable, provide information about any medications you are currently taking. Include the name, dosage, frequency, and the reason for taking each medication. This is important as certain medications can impact fertility.
5. In the section related to your menstrual cycle, you may be asked to provide details such as the length and regularity of your periods, any associated symptoms, and the age at which you started menstruating.
6. Fill out the section regarding any previous pregnancies or attempts at pregnancy. Include information about any miscarriages, ectopic pregnancies, or stillbirths, as well as any fertility treatments you may have undergone in the past.
7. Answer questions about your lifestyle habits, such as smoking, alcohol consumption, or recreational drug use. These factors can have an impact on fertility, and it is essential to provide accurate information.
8. Finally, sign and date the form to confirm that the information provided is true and accurate to the best of your knowledge.

Who Needs Infertility History Form:

1. Individuals or couples who are seeking fertility evaluation or treatment may be required to fill out an infertility history form. This form helps medical professionals understand the patient's medical background, potential risk factors, and previous experiences related to infertility.
2. Both men and women may need to complete the infertility history form as infertility can affect both genders. This helps healthcare providers assess various factors that may contribute to infertility and develop appropriate treatment plans.

Remember, accurately filling out the infertility history form is crucial for an effective evaluation and treatment process. Providing comprehensive information can assist healthcare providers in determining the best course of action and improving the chances of a successful outcome.

For pdfFiller’s FAQs

What is infertility history form?

The infertility history form is a document that gathers information about a person's medical and reproductive history to assess their fertility status.

Who is required to file infertility history form?

Anyone seeking fertility treatment or services may be 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. It will require information about medical history, previous pregnancies, and any fertility treatments.

What is the purpose of infertility history form?

The purpose of the infertility history form is to help healthcare providers assess the fertility status of individuals seeking treatment and to tailor treatment plans accordingly.

What information must be reported on infertility history form?

Information such as medical history, previous pregnancies, current medications, lifestyle factors, and any previous fertility treatments must be reported on the infertility history form.

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