Your Fertility Audit — Gold Coast IVF & Fertility: Dr. Steven Palter, MD

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Your Fertility Audit

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Your Personal Fertility Audit (TM)

answer these short questions to instantly find out if you have a fertility problem and what your first steps to success should be
First Name
E-mail
DISCLAIMER: The information from this questionnaire is for educational purposes only and any recommendations therein are not intended to replace the advice of your healthcare professional. If you have or believe you have ADD or ADHD it is important to seek the advice of a competent healthcare professional as soon as possible.

What is your age?

under 30 30-34 35-37 38-39 40-42 more than 43

How long have you been trying to get pregnant?

less than 6 months 6-12 months more than 1 year more than 5 years

Before you started trying have you used the �rhythm method� for more than a year without pregnancy?

Yes No

Have you ever been pregnant before?

Yes No

Have you ever had a miscarriage?

No Yes, one Yes, two or more

Have you ever had an ectopic (or tubal) pregnancy?

Yes No

Have you ever had chlamydia or gonorrhea?

Yes No

Have you ever had pelvic inflammatory disease (“PID”)?

Yes No

Are your periods ever so painful you miss work or school or have to take narcotic pain relievers?

Yes No

Is sex painful?

Yes No

Have you ever been told you might have endometriosis?

Yes No

Have you ever been told you have fibroids or myomas?

Yes No

Have you ever had surgery on your ovary, fallopian tube, or uterus (womb)?

Yes No

Do you smoke cigarettes now or in the past?

Yes No

Do you use marijuana, cocaine, or heroin?

Yes No

Does your partner ever use marijuana cocaine or heroin?

Yes No

Did your partner every use steroids or hormones for bodybuilding or sports?

Yes No

Does your partner smoke any cigarettes?

Yes No

How many days of menstrual bleeding do you have each month?

less than 5 5-7 more than 7

Do you ever have bleeding so heavy it soils your clothes?

Yes No

What is your average cycle length in days from one month to the next?

less than 25 25-35 more than 35

Does your cycle vary by more than 7 days from month to month?

Yes No

Does your period ever skip months?

Yes No

Have you gained or lost more than 10 lbs in the past year?

Yes No

How much do you exercise in an average week?

None 45-60 minutes a day 60-120 minutes a day More than 120 minutes a day

Do you have facial hair or chest hair requiring regular waxing shaving etc?

Yes No

Do you have acne?

Yes No

Does your partner have trouble with erection or ejaculation?

Yes No

Does your partner have high blood pressure or diabetes?

Yes No

Do you have diabetes?

Yes No

Have you or your partner ever had cancer, chemotherapy, or radiation therapy?

Yes No

Did your mother go through menopause before age 45?

Yes No

Does anyone in you or your partner’s family have a genetic disease?

Yes No

Is worrying about getting pregnant causing fights between you and your partner?

Yes No

Is trying to get pregnant causing you to not enjoy sex?

Yes No

Are you having trouble sleeping?

yes No

Are you angry at friends and family who are pregnant?

yes No

Do you feel tired all the time?

Yes No

Please enter your height and weight (be honest!)
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