My Fertility Profile: Doctor Discussion guide - Health Tools

Roughly one-third of fertility problems are due to female factors. Therefore, it's important to consider the potential impact that your health and medical history will have on you and your partner’s ability to conceive.

Go through Steps 1 to 6 and fill in your answers. When you’ve answered all the questions and are ready to print, click on the “Print this Form” button – this will give you a printer-friendly summary of your answers (do not use the browser print option). Bring this to your doctor’s visit. This will give your doctor valuable information about factors that can affect your fertility, and it can also help get your fertility discussion started.

Step 1: General information
Step 2: Your menstrual, birth control, and pregnancy history
Step 3: Your medical and medication history
Step 4: Your lifestyle
Step 5: Your experience trying to conceive
Step 6: Questions for the doctor

Step 1: General Information

Age (years):

Height:

cm OR ft in

Weight:

kg OR lbs

Step 2: Your menstrual, birth control, and pregnancy history

	Yes	No
Are your menstrual cycles regular (about every 28-32 days)? (Cycle day 1 is the first day of bright red flow. Menstrual cycle length is calculated from cycle day 1 to the next cycle day 1.)
Are your menstrual periods painful?
Have you ever used an intrauterine device (IUD)?
Have you ever used birth control pills?
Have you ever used birth control injections or the birth control patch?
Have you ever been pregnant?
Have you had two or more medically documented miscarriages?

If you have been pregnant before, complete the following for each pregnancy:

Year of pregnancy	Outcome (e.g., miscarriage, abortion, stillbirth, live birth)

Step 3: Your medical and medication history

Do you have a history of any of the following?

	Yes	No	Don't know
endometriosis
polycystic ovarian syndrome (PCOS)
pelvic inflammatory disease
sexually transmitted infections
abdominal or pelvic surgery
chemotherapy or radiation
diabetes
high blood pressure

List any surgical procedures you have had (including date):

List any medications you are taking (including prescription medications, non-prescription medications, vitamins, herbal medications, homeopathic remedies, or other natural products):

Step 4: Your lifestyle

Smoking (Cigarettes per day)

Alcohol (Drinks per week)

Coffee or caffeinated drinks (per day)

Step 5: Your experience trying to conceive

	Yes	No
Are you currently trying to conceive?
If yes, how long have you been trying to conceive?
Have you tried tracking your ovulation with a basal body temperature (BBT) chart or an ovulation predictor kit?
Have you been diagnosed with fertility problems by a health care provider?
If so by whom? obstetrician/gynecologist primary care physician fertility specialist/reproductive endocrinologist (RE) other

Step 6: Questions for the doctor

Questions for the doctor:

	Yes	No
Have you had a semen analysis?
Have you ever been diagnosed with a sexually transmitted infection?