Advanced Fertility Services
Ask the Doctor Form

PERSONAL INFORMATION

Required information is indicated by *
Your Full Name *
Your Husband's/Partner's Full Name
Optional Information - Please fill out if you want us to contact you
Address
City
State
Zip Code
Email *
Telephone
Cell/Mobile

I have a question regarding

How long are you married	years months
How long have you been trying to get pregnant?	years months
What type of physician are you seeing?
Reason for Infertility (Why do you or your doctor think you are not getting pregnant?)	(press control to select more than 1 options)

FEMALE MEDICAL HISTORY

Date of Birth (MM/DD/YR)
Age
Height
Weight
Menstrual periods occur every	days
Are they regular?	Yes No
How long are your periods?	days
Have you been told you have endormetriosis?	Yes No
Have you ever had pelvic inflammatory disease (PID)?	Yes No
Have you ever had pelvic surgery??	Yes No
Number of pregnancies with current partner?
Number of pregnancies with previous partner?
Have you had any miscarriages? Abortions?	Yes No
Have you ever had a tubal (ectopic) pregnancy?	Yes No
Are there any live births?	Yes No

Do you have any of the following symptoms? If you do, you might have a thyroid issue.	(press control (Ctrl) to select more than 1 options)
Current Medical Problems and Medications

MALE MEDICAL HISTORY

Date of Birth (MM/DD/YR)
Age
Are there any pregnancies with previous partner?	Yes No
If yes, how many?
Do you have problems with erection or ejaculation?	Yes No

Semen Analysis Report

Have you had a semen analysis?	Yes No
If yes, when? (MM/DD/YR)
What was the sperm count	(millions per mL)
Motility?	%
Morphology (Normal/Abnormal)

MEDICAL TESTS

Hysterosalpingogram ( X-ray of the uterus and tubes)	Yes No
Laparoscopy (telescope placed through the belly button to see inside your abdomen)	Yes No
Hysteroscopy (telescope placed into the uterus through the vagina to see the inside of the uterus)	Yes No

HORMONAL BLOOD TESTS

FSH (Follicle Stimulating Hormone)	Yes No
LH (Luteinizing Hormone)	Yes No
AMH (Anti-Mullerian Hormone)	Yes No
Prolactin	Yes No
TSH (Thyroid Stimulating Hormone)	Yes No
ATA (Anti-Thyroid peroxidase Antibodies )	Yes No
ATG (Anti-Thyroglobulin Antibodies)	Yes No
Other	Yes No

MEDICAL TREATMENT

Ultrasound Monitoring	Yes No
Clomiphene stimulation with intercourse	Yes No
Clomiphene stimulation with insemination (IUI)	Yes No
HMG stimulation with intercourse	Yes No
(IUI) without any stimulation	Yes No
Injectable HMG stimulation with insemination (IUI)	Yes No
In Vitro Fertilization (IVF)	Yes No
Intracytoplasmic Sperm Injection (ICSI)	Yes No
Are there other pertinent test results, procedures or problems that need to be identified?
If you have any questions for the doctor?

DISCLAIMER

We would like to alert you that the purpose of this web site is to provide you with medical and health information only. This website is to be used only to provide you with additional information for the sole purpose of better understanding your health and your health conditions. AFS "Ask the Doctor" cannot differentiate serious from non-serious forms of certain symptoms and always advises you to consult your physician if you feel ill.

AFS "Ask the Doctor"offers current, factual, and medically relevant answers to questions received from our visitors. However, these responses are only educational and informative in nature and cannot in any way be used to represent a complete analysis or diagnosis. Clearly, since due to the inherent nature of the Internet a comprehensive physical examination is not possible, the medical information provided herein cannot be used as an alternative to a consultation by a physician or any other medical professional.

Any and all parties associated with Advanced Fertility Services are not liable in any form. Users cannot have any cause-of-action against Advanced Fertility Services, or any associated persons, whether the information provided was used as directed or otherwise. AFS "Ask the Doctor" does not provide medical advice, such as that provided through a direct consultation and is not intended to replace it. Users shall not solely rely upon the information provided by Advanced Fertility Services, as specific medical diagnoses require the seeking of medical advice from a licensed physician.

Information accessed through this online site is provided "AS IS" and without warranty, express or implied. All implied warranties of merchantability and fitness for a particular use or purpose are hereby excluded. You access our materials at your own risk.

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