Get Infertility Questionnaire - Idaho Urologic Institute

Filling out the infertility questionnaire is an important step in evaluating and addressing infertility concerns. This guide provides clear instructions to help you complete the form accurately and efficiently, ensuring that your physician has the necessary information to support your journey.

Follow the steps to successfully complete the infertility questionnaire online.

1. Press the ‘Get Form’ button to obtain the infertility questionnaire and open it in an online editor.
2. Begin with section A, where you will provide general information. Fill in the date, your phone number, your name, your age, your partner's name, and their age, followed by your occupation and your partner's occupation.
3. Move to section B, Fertility History. Here, indicate your relationship status and the duration of your current relationship. Provide details on how long you have been trying to conceive and any previous pregnancies you may have had, including ages and genders of children, if applicable.
4. Continue by stating whether you or your partner have undergone any infertility evaluations or treatments and provide the relevant details, including dates and types of treatments.
5. In section C, Sexual History, answer questions about any issues with erections, use of lubricants, timing of intercourse, and frequency of sexual activity.
6. Proceed to section D, Childhood, where you will disclose any childhood medical issues related to reproductive health.
7. In section E, Medical History, provide any relevant medical problems, medications, allergies, and past diagnoses of low .
8. For section F, Surgical History, list any previous surgeries you have undergone.
9. Section G addresses infections. Indicate whether you have had infections involving the kidneys, prostate, testicles, epididymis, or urethra.
10. In section H, Exposure, note any exposure to pesticides, chemotherapy, anabolic steroids, high temperatures, or X-rays in the past six months.
11. Move to section I, Social History, and mention your alcohol consumption and smoking habits, if any.
12. Finally, in section J, Family History, indicate if there is a family history of infertility, cystic fibrosis, or hormonal imbalance, along with the relationship to the individual.
13. Before submitting the form, review all sections for accuracy. You can save changes, download, print, or share the completed form as necessary.

Complete the infertility questionnaire online to move forward with addressing your fertility concerns.