|
FERTILITY HEALTH HISTORY FORM |
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| Date:______________________ |
| Your Name:____________________________________
Age:________ |
| Spouse's Name:_________________________________
Age:________ |
|
|
| 1. Name of your medical doctor
_______________________________. |
| |
| 2. Name of other health care providers worked
with during infertility related problems. |
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| 3. Briefly summarize your infertility history: |
|
Length of infertility struggles |
| Diagnosis |
| Number of pregnancies |
| Kind of pregnancy
losses |
| |
| 4. List the number of attempts of assisted
reproductive technology (if any) and results: |
|
|
| 5. Names and ages of current children, if any: |
| |
| 6. Current procedures scheduled (or to schedule
soon): |
|
|
| 7. Have you considered any other fertility
options to create your family? |
| |
| 8. Do you have any marital issues that you
would like to address? If so, please explain. |
|
|
| 9. How emotionally difficult is you experience
with infertility? |
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| Scale: 0=Not Difficult, 3=Somewhat Difficult, 6=Very
Difficult |
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| Depression
0 1 2 3 4
5 6 |
| |
| Anxiety
0 1 2 3 4
5 6 |
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| Other
0 1 2 3 4
5 6 |
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| Tell me about your support system? |
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| In what ways do you handle your life stress? |
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