IVF Patient Questionnaire
Patient’s Name:
Partner’s Name:
Address:
City, State, Zip:
Daytime Phone Number:
Evening Phone Number:
  The entry below is mandatory - Please type a valid Email address
Email address:
1 Why do you require IVF? tubal factor, male factor, ovulatory problem, other indication
2 Cause of infertility:
3 Age: Date of Birth:
4 Height: Weight:
5 Length of average menstrual cycle (Day 1 of flow until the next Day 1 of flow): days
6 Source of semen: husband ejaculation, donor, fresh specimen,
frozen specimen, Testicular biopsy or aspirated sperm
7 Do you have a history of any endocrine disorder other than an ovulatory dysfunction
(i.e. thyroid disease)?		 Yes No
8 Are you currently being treated for anxiety or depression (or another psychiatric disorder)? Yes No
9 Do you have a history of ovarian hyperstimulation syndrome? Yes No
10 Do you have a history of polycystic ovaries? Yes No
11 Do you have a history of endometriosis? Yes No
12 Do you have a hydrosalpinx (dilated Fallopian tube)? Yes No
13 Do you have a history of uterine fibroids or polyps? Yes No
14 Have you had a history of more than 1 unsuccessful fresh IVF cycle? Yes No
15 Do you have a history of more than 2 consecutive clinical miscarriages (gestational sac observed on ultrasound)? Yes No
16 Do you have a history of a poor response to fertility medications? Yes No
17 Have you ever been diagnosed as being perimenopausal or having decreased ovarian functioning? Yes No
18 Do you have a history of any medical condition for which you are under a doctor’s care? Yes No
19 Do you regularly take any prescription drugs regularly other than those prescribed for infertility treatment? Yes No
20.a. Do you smoke? Yes No
20.b. If so, how much?
21.a. Do you have a history of substance abuse? Yes No
21.b. Within the last 12 months? Yes No
22. Do you have a history of any drug allergies or sensitivities? Yes No
If you have answered yes to any of the above questions please explain in the space provided below.
 
The information provided in this form is considered confidential and/or privileged and is intended only for the internal use at Fertility Centers of Illinois. This information will not be shared with any third party organization.

If we find that you do not qualify for this study, do we your permission to keep your information for our files? (If no, we will destroy this information immediately.)
Yes No