Get Hysterosalpingogram (hsg) Questionnaire / Consent - Xrays 2020-2025

Filling out the Hysterosalpingogram (HSG) Questionnaire/Consent form online is a crucial step in preparing for your procedure. This guide provides a clear and supportive approach to ensure you complete the form accurately and effectively.

Follow the steps to fill out the questionnaire with ease.

1. Press the ‘Get Form’ button to access the HSG Questionnaire and open it in your preferred editor.
2. Begin filling out your personal information, including your name and date of birth. Ensure that all information is accurate.
3. Indicate the first day of your last menstrual period. This information is critical for your medical history.
4. Specify the duration of your periods and the length of your menstrual cycle by filling in the appropriate details.
5. Describe the flow of your menstrual period by selecting options for light, normal, or heavy.
6. Answer whether you have had unprotected sex since your last period by selecting 'Yes' or 'No'.
7. If applicable, indicate whether you have ever been pregnant and provide further details regarding the number of pregnancies, miscarriages, abortions, and children.
8. If you have children, note their ages in the specified field.
9. Respond to inquiries about any previous pelvic surgeries, including cesarean sections and laparoscopies, by selecting 'Yes' or 'No' and providing details if required.
10. Indicate whether you have had a pelvic sonogram/ultrasound by choosing 'Yes' or 'No'.
11. Specify if your partner has been checked for sperm count, answering with 'Yes' or 'No'.
12. State whether you are currently taking any fertility drugs or have taken birth control pills and for how long.
13. Answer questions regarding any past hysterosalpingograms (HSG), including the time since the last one and its results.
14. List any current medications you are taking in the provided space.
15. Document any allergies you may have, including to X-ray contrast, iodine, shellfish, and medications. Provide details where applicable.
16. Review the consent section carefully, confirming your understanding that the test may involve risks and that you are not pregnant.
17. Provide your signature and date, along with the signature of an authorized representative if necessary, and the witness and radiologist signatures.
18. Once all sections are completed, review your responses for accuracy before saving, downloading, or printing the completed form.

Complete your HYSTEROSALPINGOGRAM (HSG) Questionnaire/Consent form online today for a smoother process.