Fertility Consultation Intake

Name:
Partners Name
Your e-mail:
Contact phone #
Do you currently have any children?
How long you have been trying to conceive?
# of Miscarriage(s)
Do you have a definitive diagnosis regarding your fertility? If so, what is it?
Are you currently using Assisted Reproductive Technology (ART)?
 yes no
What (ART) procedures have you used and when?
What other fertility support methods have you used?
Are you currently working?
 yes no
Full or Part Time?
What is your occupation?
Do you enjoy your work?
 yes no
Number of hours worked per week:
If you could do something else, what would it be?
On a scale of 1 to 10 (10 being to highest), how much stress do you experience?
What medications are you currently taking?
What vitamins and/or supplements are you currently taking?
Are you a vegetarian?
 yes no
Do you eat a small/moderate/large amount of sugar?
Do you smoke?
 yes no
Drink caffeine?
 yes no
Alcohol?
 yes no
What is your weight in pounds?
Height?
What is your age?
Your partner’s age?
Please describe your nutrition (i.e. on an average what do you eat for breakfast, lunch, dinner and any snacks):
What is the most difficult aspect for you regarding infertility?
Do you believe, deep down, that it is possible for you to get pregnant and birth a healthy baby?Please explain:
What are your main objectives in seeking the support of a fertility expert?
Please tell me anything else that is important to you:
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