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Fertility Questionnaire


Female Questions

1.Are you 35 or older?

2.Did/do you have bad pain during periods? (Unable to attend school/work)

3.Do you have a family history of Endometriosis or Menopause prior to age 48?

4.Do you have cycles that are outside of 27-29 days on a regular basis?

5.Do you have a strong family history of Type 2 Diabetes, acne, facial hair, or cycles ≥ 30 day intervals?

6.Do you experience hypoglycemic symptoms on a regular basis (severe hunger, shakiness, mood swings,

extreme fatigue, nausea, headaches)?

7.Do you often have sweet or carbohydrate cravings?

8.Are you or have you ever been a heavy aerobic exerciser (More than 30-40 minutes 3x a week) for

1 year or more? (dancers, gymnasts, ice skaters, swimmers included)

9.Have you ever been very thin (for any reason)? i.e. your family and friends told you that you needed to gain weight

10.Have you had an STD, Pelvic Inflammatory Disease (PID), or a significant intra-abdominal

infection such as Appendicitis, or a history of tubal infection?

11.Do you have significant PMS symptoms (pre-cycle mood changes, bloating, or headaches)?

12.Do your cycles routinely last 6 or more days?

13.Do you suffer from anxiety and stress that is hard to control or needs medication?

14.Did you have a diagnosis of PCOS or Endometriosis at any age?

15.Are you overweight (BMI ≥ 30)?

16.Do you drink more than 6 drinks per week or smoke?

Male Questions

1.Are you 40 or older?

2.Do you have erection problems or low libido?

3.Have you ever used steroids for body building, marijuana, or are a current user of a calcium

channel blocker (blood pressure medicine)?

4.Are you overweight (BMI ≥ 30)?

5.Do you snore loudly?

6.Do you have metabolic syndrome or Type II Diabetes, borderline Diabetes, or pre-diabetes?

7.Do you have more than 6 drinks per week or smoke?

If you answered yes to any of these questions contact JCRM at 904-493-BABY(2229) to schedule a consultation with a fertility specialist. Many couples have problems that require immediate attention prior to trying for a pregnancy. This questionnaire is designed to identify such couples. For example, many ovulation problems predispose patients to miscarriage. In some cases miscarriage rates could be as high as 60%. Attention to these and other issues ahead of time could dramatically reduce complications and increase the month to month pregnancy rate.

We also offer a service to have a fertility evaluation called “Check My Fertility.” In this service, we use our detailed review of your history to identify potential problems and would recommend a few very basic tests. This process, can identify subtle issues that might be missed in our questionnaire above. Couples at risk for age related problems, are one of the important areas we try to identify that can be significant even in the 20’s age group (female age). This service is helpful for couples who are thinking about putting off fertility for school or career reasons or the couple who is planning to start trying for a pregnancy. With couples waiting later to start trying in today’s world, increasing the time to pregnancy is important. Fertility is a couples diagnosis, and we see too many couples who essentially waste a great deal of time and then run into age related issues that only complicate their situation further.

Check My Fertility Evaluation

  • Covered by most insurance plans
  • If you don’t have insurance or your plan does not cover fertility evaluations, we have an affordable charge of $300 which includes:

Extensive history and record review

Preliminary Fertility Evaluation

Create individualized Fertility workup

Interested in a Fertility Evaluation? Schedule a tentative appointment here!