Study ID:

Patient Number:

Participant's first name:

Last name:

Middle initial:

1. How old were you when you had your first monthly period?

2. During most of your life were your periods regular, about once per month? (Do not include times that you used birth control pills.)
Yes
No

3. Were there times that you did not have a period for at least six months? (Not counting pregnancy or breast feeding.)
Yes
No

4. Have you ever been pregnant? It is important that we know about all of your pregnancies, including live births, still birtths, miscarriages, tubals (ectopics), and abortions.
Yes (also complete questions 4a to 4f)
No (proceed to question 5)

4a. How many times have you been pregnant?

4b. Ever had a pregnancy that lasted at least 6 months?
Yes
No

4c. How many live births have you had?

4d. How many still births have you had?
(From a pregnancy lasting at least 6 months.)

4e. How many spontaneous miscarriages?

4f. How many tubal (ectopic) pregnancies?

5. Have you ever tried to get pregnant for more than
one year without becoming pregnant?
Yes (go to question 5a)
No (proceed to question 6.)

5a. Did you visit a doctor or cinic because you didn't get pregnant?
Yes (also answer 5b through 5e)
No (proceed to question 6)

Please provide contact information for doctor or clinic:

5b. Name of doctor/clinic:


5c. Address (including city, state, zip):

5d. Phone number:

5e. When did you last vist the doctor/clinic?

6. What was the reason you did not become pregnant? (Mark all that apply.)
Problem with hormones or ovulation (did not produce eggs)
Problem with tubes or uterus
Endometriosis
Problem with partner
Don't know

Other problem (specify):

7. If you have been treated for infertility in the past, what treatment did you receive?
Surgery
Artificial insemination
Clomid or other fertility medications
IVF

Other:

8. When did you first try to become pregnant without success?

9. When did you last try to become pregnant?

10. Did you have a hysterosalpingogram or laparoscopy to look at your tubes?
Yes (also complete 10a and 10b)
No (proceed to question 11)

10a. When did you have this test?

10b. Was the test normal?
Yes
No

11. Did your partner have a semen analysis?
Yes (complete 11a and 11b)
No (proceed to 12)

11a. If Yes, When did he have the test?

11b. Was the semen test normal?

12. Did you have any blood tests to prove that you ovulate?
Yes (complete 12a and 12b)
No (Finished! please click "Submit")

12a.When did you have the test?

12b.Was the test normal?