infertilty-questionnaire

940 E. El Camino Real
Sunnyvale, CA 94087
harminder@homeopathicvibes.com
www.homeopathicvibes.com
Office Phone (408)737-7100
Office Fax (408)737-7102

Name *

First

Last

Email *

Partner's Name *

First

Last

How old were you when you had you first period

How frequently do your periods come? Every ___days

How long do your periods last? _____days.

When did your last period start?

Do you experience cramping with your periods?

If yes, when during your cycles do you have pain (check all that apply) :

Before
During
After

How would you describe the cramps?

Mild
Moderate
Severe

Do you take pain medication for the cramps?

Yes
No If yes, specify

Medication

Do you bleed or spot between periods?

If yes, please describe:

Have you ever had an abnormal Pap smear result?

If yes, what therapy was required

Cryotherapy(freezing of cervix)
Laser therapy
Cone biopsy
LEEP

Other

Have you ever had any of the following infections involving any part of the reproductive tract? (Vagina, cervix, uterus, ovaries )?

What treatment did you receive? Year:____

Do you have pain with intercourse?

Never
Sometimes
Frequently
Always

If yes, does the pain remain in your lower abdomen after intercourse if over ?

Yes
No if yes

For how many minutes?

How frequently do you and your partner have intercourse? _____per week/Month

How frequently do you and your partner have intercourse around ovulation? ____times per month

Do you usually use lubrication during intercourse?

If yes, please specify

Have you experienced any difficulties with intercourse that may be contributing to infertility?

Yes
No If yes

Please explain:

Have you ever used contraception in the past?

Other

How long have you and your partner been attempting to achieve pregnancy?

Have you been using temperature charts?

If yes, for how long?

Have you been using urine ovulation predictors?

Yes
No if yes

what kind and for how long?

Have you ever tried to achieve a pregnancy with a different partner

Have you ever conceived with a different partner?

Has your male partner ever gotten someone else pregnant?

Have you been treated for infertility previously?

If Yes, where/when

What was the cause of infertility?

Have you ever had intrauterine inseminations (IUI)?

If so, for how many cycles?

If yes, specimen was provided by : Check all that apply

Partner
Donor

Have you ever attempted in vitro fertilization(IVF)?

Yes
No if yes, please specify below

Have you ever been pregnant ? (including elective terminations, miscarriages, births)

Out Come

How long to conceive

Infertility treatment?

Pregnancy complications?

Is current partner the farther

Have you ever had any surgeries in the past?

Type

Findings of surgery:

Heat/Cold intolerance recently?

If yes, please explain:

Unusual hair distribution changes or breast nipple discharge?

If yes, please explain:

Significant weight change in the last year? If so, please describe how many lbs and over what time:

Do you smoke?

If yes, how many packs per day?

Do you take hot baths?

Do you drink alcohol

If yes, how many alcoholic beverages per week:

Do you smoke marijuana

If yes, how much per week:

Do you exercise regularly?

if yes, please indicate type of exercise and estimate hrs per week spent

Are you allergic to any medication?

If yes, please indicate name of medication and type of reaction Medication Reaction

Are you currently taking any prescription medications

Medication Reaction

Do any of you use herbal medications?

If yes, types of medications used:

Which of the following test have already been performed?

Semen analysis
Chromosome test
Hamster egg penetration test

other (please specify):

Have you ever had any significant testicular injury?

If yes, please describe:

Have you ever had any road accidents?

If so, please furnish detail

Do you feel like passing of semen or any abnormal fluids

Before Urination
After Urination
After Stool

Does the discharge of semen occur during sleep?

Do you feel your penis is bent or loose towards the left side?

Do you get perfect erection before intercourse?

Do you feel weakness after the intercourse?

Are you suffering from premature ejaculation?

Are you suffering from premature ejaculation? (copy)

What is your usual duration of intercourse with current partner/wife?

Less than 5 minutes.
More than 5 minutes.
More than 10 minutes.

What was your usual duration of intercourse with previous partner if any?

Do not apply.
Less than 5 minutes.
More than 5 minutes.
More than 10 minutes.

Do you ever had the habit of masturbation

If so, since how long? ___________How often_____

Before erection?

After erection?

How many times a month you do intercourse?

How many times night discharge occurs in a week?

Do you read vulgar & obscene literature?

Do you watch vulgar & obscene movies?

Do you imagine romantic fantasies

Does your underwear get wet when you see nude photographs

Are you a

Vegetarian
Non Vegetarian?

Which types of food do you like?

Spicy
Mild?

Do you have Gastric Problem?

Do you have constipation?

Do you smoke?

If yes, how many packs per day?

Do you drink alcohol

If yes, how many alcoholic beverages per week:

Do you smoke marijuana

if yes, how much per week:

Do you take hot baths

If yes, how much per week:

Do you exercise regularly?

if yes, please indicate type of exercise and estimate hrs per week spent

How many times you wake up to urinate during night?

I don’t wake up.
1-3 times.
4-6 times.
More than 6 times.

Do you feel pain after urination?

Do you take your food timely?

Do you take hot milk at bed time?

Is your wife older than you?

If so how many years?

How about your memory?

Sharp
Weak

Did you ever taken any street drugs?

Regular
Occasionally
Never

Do you take any alcoholic drinks?

Daily
Occasionally
Never

If so details

How long?

What are your expectations from our treatment?

I don’t expect good results.
I expect good results.
I would be happy if I improve.
I am confident.

Are you willing to make changes to your life style or diet modifications?

I can not change my lifestyle.
I have tried nothing works for me,
I am willing to change my lifestyle if needed.
I am willing to do what ever is needed to get results,

Are you currently taking any prescription medications?

Medications/Reason:

Do any of you use herbal medications?

if yes, Have you ever taken any of the medications listed below?

Other (please list):

Have you ever had any surgeries in the past

If yes, please indicate date, type, findings of surgery:

Other

Have you noted any significant? Heat/Cold intolerance recently?

If yes, please explain:

Unusual hair distribution changes?

If yes, please explain:

Significant weight gain or loss in the last year? If so, please describe how many lbs and over what time:

Are you allergic to any medication?

If yes, please indicate name of medication and type of reaction Medication Reaction

Name