Form – Fertility Assessment Form Fertility Assessment Form Couples Background Information Date(Required) MM slash DD slash YYYY Male's Name(Required)Female's Name(Required)1. How long have you been trying to conceive? Has a semen analysis been performed? If so when?2. Have you had any diagnostic testing to rule out anatomical causes of infertility (male and female)? If yes, then list when and what studies were performed.3. Is there any history of infertlity in the family? If yes please provide more information.4. Do you know of any potential causes of your infertility? If so please provide details.5. Have you consulted with a fertility specialist? If so please provide details.6. Have you had any ferlitly treatments ? If so please provide details.Female Section1. Do you know when you mother transitioned into menopause?2. Do you have regular menstrual cycles? If yes please provide details.3. Is there a history of any type of birth control? If yes please provide more details4. Is there any history of hormone replacement? If so please provide details.5. Have you ever been diagonsed with polycystic ovarian syndrome? (PCOS) If so please provide details.6. Have you ever been diagnosed with diabetes or pre-diabetes? If so please provide details.7. Have you been diagnosed with endometriosis, uterine fibroids, cysts or benign growths? If so please provide details.8. Have you ever been diagnosed with cervical stenosis? If so please provide details.9. Have you ever been diagnosed with an autoimmune disease? If yes please please provide details if you or a family member have been diagnosed.10. How would your rate your body mass? Please check one. Normal Underweight Overweight 11. Have you ever had an STI or HIV? If so please provide details.12. Have you ever been diagonsed with a pelvic inflammatory condition? If so please provide details.13. Have you ever had any pelvic surgeries or procedures? If so please provide details.14. Do you smoke/vape cigarettes or marijuana? Or taken illicit drugs? If so please provide details.Medications: Antihistamines Cough suppressants Atropine Sinus congestion medications Propantheline Clomid Steroids Anti-neoplastic medications Chemotherapy Autoimmune medications Antidepressant medication Epilepsy medication Blood pressure medication Cocaine Hormones (estrogen, progesterone, testosterone) Protonics- antacids Motility Medications Opioids Antipsychotic medications Hallucinogens Please mark any medications that you currently use or have used in the past. Endometriosis:Select 0=never, 1=sometimes, 2=frequently, 3= most of the timeDo you experience painful menstrual cycles? 0 1 2 3 Do you experience pain with intercourse? 0 1 2 3 Do you experience pain with urination or bowel movement? 0 1 2 3 Do you experience abnormal menstrual bleeding? 0 1 2 3 Hyperlactinemia:Select 0=never, 1=sometimes, 2=frequently, 3= most of the timeDo you ever experience a milky discharge from your nipples? 0 1 2 3 Do you ever experience vaginal dryness? 0 1 2 3 Do you experience pain with intercourse? 0 1 2 3 Do you have reduced sex drive? 0 1 2 3 Hypothyroidism:Select 0=never, 1=sometimes, 2=frequently, 3= most of the timeDo you experience fatigue? 0 1 2 3 Do you experience reduced brain endurance? 0 1 2 3 Do you experience reduced muscle endurance? 0 1 2 3 Have you noticed hair thinning or hair loss? 0 1 2 3 Do you have difficulty regulating body temperature? 0 1 2 3 Male Section1. Do you have a history or hormome or testosterone replacement therapies? If so please provide details.2. Have you ever been diagnosed with andropause or endocrine disorder? If so please please provide3. Have you ever been diagnosed with erectile dysfunction? If so please provide details.4. Have you ever beem diagnosed with a varicocele or testicular infection? If so please provide details.5. Have you ever had any pelvic surgeries (hernia,prostate,testicular, rectal)? If so please provide details.6. Have you ever been diagnosed with prostatis? If so please provide details.7. Do you smoke/vape cigarettes or marijuana? Or taken illicit drugs? If so please provide details8. Have you ever been diagnosed with diabetes or pre-diabetes? If so please provide details.9. Do you have any penis deformities or an undescended testes? If so please please provide details.10. Have you ever been diagnosed with an autoimmune disease? If so please provide details.11. How would your rate your body mass? Please check one. Normal Underweight Overweight 12. Have you ever been infected with an STI or HIV? If so please provide details.13. Have you ever been diagnosed a pelvic inflammatory condition? If so please provide details14. Have you had any exposure to chemotherapy or radiation? If so please provide details.15. Do you drink alcohol? If so please provide details.16. Do you consume caffeine? If so please please provide details.17. Do you exercise? If so please provide details.Hyperlactinemia:Select 0=never, 1=sometimes,2=frequently, 3= most of the timeDo you ever experience a milky discharge from your nipples? 0 1 2 3 Do you ever experience vaginal dryness? 0 1 2 3 Do you experience pain with intercourse? 0 1 2 3 Do you have reduced sex drive? 0 1 2 3 Andropause:Select 0=never, 1=sometimes, 2=frequently, 3= most of the timeDo you experience fatigue? 0 1 2 3 Do you experience reduced brain endurance? 0 1 2 3 Do you experience reduced muscle endurance? 0 1 2 3 Have you noticed hair thinning or hair loss? 0 1 2 3 Do you have difficulty regulating body temperature? 0 1 2 3 Hypothyroidism:Select 0=never, 1=sometimes, 2=frequently, 3= most of the timeReduced muscle endurance 0 1 2 3 Reduced sexual endurance? 0 1 2 3 Reduced muscle mass 0 1 2 3 Reduced motivation and drive 0 1 2 3 Medications: Ulcer medications Steroids Chemotherapy Antineoplastic medications Seizure medications Antidepressants Antifungal medications Calcium channel blockers Psoriasis medications Please mark any medications that you currently use or have used in the past.CAPTCHANameThis field is for validation purposes and should be left unchanged. Please do not submit any Protected Health Information (PHI).