Women’s Fertility History Form - Amber Wellness Group

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Amber Wellness Group, PLLC 1944 NE 45th Ave. Portland, OR 97213

Name(Required)

First Last

Date(Required)

MM slash DD slash YYYY

Are you working with a Reproductive Endocrinologist?(Required)

If yes, Last Apt. Date with RE:

Name Of Physician:

Name of Clinic:

How long have you been trying to conceive? - Months Years

Have you received a diagnosis regarding the reason for your infertility?(Required)

Please explain:

Age of Menarche (first period):(Required)

Date of Last Menses (First Day)(Required)

Have your cycles changed since they first began?(Required)

Please Explain:

Cycle Length (Number of days between day one and next day one of menses)(Required)

Painful Periods:(Required)

How many days does the pain last?

Number of days of bleeding

Color of Blood:

Heaviness of Flow

Are your cycles(Required)

Irregular cycles. please explain:

Spot between periods?(Required)

Every Month?(Required)

Do you experience PMS?(Required)

PMS

Please explain other PMS

Number of Pregnancies:(Required)

Abortions(Required)

Miscarriages(Required)

Children(Required)

Adoption(Required)

Have you had a D & C(Required)

How many times and Dates:

Times

Dates

Date of Last Pap Smear: ____________ Abnormal Pap Smear?(Required)

Hidden

Present Date

HPV?(Required)

Have you ever had(Required)

Cervical Biopsy

Cauterization

Conization

Operation

Other Treatments

Please explain the other treatments

Have you had your Uterus / Fallopian Tubes Evaluated (HSG)?(Required)

Laparoscopy(Required)

Vaginal Discharge:(Required)

Color

Vaginal Dryness:(Required)

Have You Been Diagnosed with Vulvodynia(Required)

Vaginal Infections:(Required)

Have you been diagnosed with:(Required)

PID

Uterine Fibroids

Polyps

Pelvic Adhesions

Endometriosis

Unexplained Other

Unexplained Other:

Do you experience pain with intercourse:(Required)

Do you find it difficult to achieve an orgasm(Required)

Is your Libido:(Required)

Do You Ovulate?(Required)

What day of Your Cycle Typically?(Required)

How are you tracking your ovulation?(Required)

Ovulation Test Kits

Basal Body Temperature

Cervical Fluid

Have you used Clomid?(Required)

How Many Cycles?(Required)

Have you or are you currently or do you plan to have fertility treatments?(Required)

Please list any Past, Present, Future Treatments and Dates:(Required)

Please Indicate any tests you have completed and dates (or approximate month and year):

Click HERE to download the file. Once completed, please save and see link to the right to upload it for our review.

Please upload your tests(Required)

Max. file size: 32 MB.

Please list any gynecological surgeries or procedures(Required)

Procedure:

Reason For:

Date Performed:

Please list past medications used specifically for gynecological conditions, including contraceptives(Required)

Medication

Prescribed for:

Date Performed:

Please list medication used specifically for fertility treatments:(Required)

Medication

Prescribed for:

Date Performed:

Have you ever had an IUD?(Required)

IUD in past from _________ to _________

Have you ever taken Depo Provera?(Required)

When did you take Depo Provera?

I understand that I am providing details of my fertility history to Amber Wellness Group, PLLC for informational purposes only. Amber Wellness Group, PLLC can not guarantee fertility success, but will provide support as you go through your fertility process. I have provided complete and accurate information to Amber Wellness Group, PLCC so that the practitioners can provide the best care possible.(Required)

I understand that I am providing details of my fertility history to Amber Wellness Group, PLLC for informational purposes only. Amber Wellness Group, PLLC can not guarantee fertility success, but will provide support as you go through your fertility process. I have provided complete and accurate information to Amber Wellness Group, PLCC so that the practitioners can provide the best care possible.

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