Fertility Clinic Intake Form

The Fertility Clinic Intake Form is purpose-built for reproductive endocrinology and infertility (REI) practices, capturing the detailed reproductive, gynecologic, and andrologic history that fertility specialists need for comprehensive evaluation and treatment planning. This template collects patient demographics alongside a thorough reproductive history including duration of infertility, prior conception attempts (timed intercourse, ovulation induction, intrauterine insemination, in vitro fertilization), pregnancy history with detailed outcomes (live births, miscarriages with gestational age, ectopic pregnancies, stillbirths, terminations), and the results of any prior fertility workup including ovarian reserve testing (AMH, day-3 FSH/estradiol, antral follicle count), hysterosalpingography or saline infusion sonography findings, and semen analysis results.

Designed for reproductive endocrinology practices, IVF centers, fertility preservation programs, and donor/surrogacy coordination clinics, this form includes sections for menstrual cycle documentation (cycle length, regularity, dysmenorrhea, menorrhagia, amenorrhea duration), gynecologic surgical history (laparoscopy, hysteroscopy, myomectomy, tubal surgery, ovarian cystectomy, endometriosis excision), endocrine screening (thyroid function, prolactin, DHEA-S, testosterone, PCOS criteria), male partner reproductive history (prior paternity, varicocele, cryptorchidism, ejaculatory dysfunction, hormonal evaluation, prior semen analyses with morphology assessment using Kruger strict criteria), and lifestyle factors affecting fertility (BMI, smoking, alcohol, caffeine intake, exercise patterns, occupational exposures, recreational drug use).

The psychosocial screening section captures the emotional impact of infertility, prior counseling or support group participation, relationship status, third-party reproduction considerations (donor egg, donor sperm, gestational carrier), and insurance coverage for fertility treatments including state mandate verification. Both partners can complete relevant sections, and the form accommodates same-sex couples and single parents by intended method. All fields are HIPAA-compliant and optimized for the REI workflow. The four-page format allows patients to document their fertility journey comprehensively before the initial consultation, enabling the specialist to identify diagnostic gaps, prioritize the evaluation, and discuss evidence-based treatment options at the first visit.