Form – Fertility Assessment Form

Fertility Assessment Form

Couples Background Information

MM slash DD slash YYYY

Female Section

10. How would your rate your body mass? Please check one.
Medications:
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 time
Do you experience painful menstrual cycles?
Do you experience pain with intercourse?
Do you experience pain with urination or bowel movement?
Do you experience abnormal menstrual bleeding?

Hyperlactinemia:

Select 0=never, 1=sometimes, 2=frequently, 3= most of the time
Do you ever experience a milky discharge from your nipples?
Do you ever experience vaginal dryness?
Do you experience pain with intercourse?
Do you have reduced sex drive?

Hypothyroidism:

Select 0=never, 1=sometimes, 2=frequently, 3= most of the time
Do you experience fatigue?
Do you experience reduced brain endurance?
Do you experience reduced muscle endurance?
Have you noticed hair thinning or hair loss?
Do you have difficulty regulating body temperature?

Male Section

11. How would your rate your body mass? Please check one.

Hyperlactinemia:

Select 0=never, 1=sometimes,2=frequently, 3= most of the time
Do you ever experience a milky discharge from your nipples?
Do you ever experience vaginal dryness?
Do you experience pain with intercourse?
Do you have reduced sex drive?

Andropause:

Select 0=never, 1=sometimes, 2=frequently, 3= most of the time
Do you experience fatigue?
Do you experience reduced brain endurance?
Do you experience reduced muscle endurance?
Have you noticed hair thinning or hair loss?
Do you have difficulty regulating body temperature?

Hypothyroidism:

Select 0=never, 1=sometimes, 2=frequently, 3= most of the time
Reduced muscle endurance
Reduced sexual endurance?
Reduced muscle mass
Reduced motivation and drive
Medications:
Please mark any medications that you currently use or have used in the past.
This field is for validation purposes and should be left unchanged.

Please do not submit any Protected Health Information (PHI).