Female Infertility Assessment | Tania's Medical and Infertility Center

Full Name

Age

Your email*

Contact Number

Height (cm)

Weight (kg)

Menstrual History, Age at first period (Menarche)?

Age 8-12

Age 13-15

Age 16+

Dont Remember

Cycle Regularity:

Regular (21-35 days)

Irregular (varying lengths)

No periods (Amenorrhea)

Average Cycle Length

< 21 days

21-35 days

> 35 days

Bleeding Duration

1-3 days

4-7 days

> 7 days

Pain During Periods

Mild

Moderate

Severe (affects daily routine)

No pain

Pregnancy and Reproductive History, Have you ever being pregnant?

Yes

No

Number of Pregnancies.

Live Pregnancies.

Miscarriages.

Ectopic Pregnancies.

If No

No

Previous Fertility Treatments

IVF/IUI

Ovulation Induction (Clomid/Letrozole)

Surgery (e.g., laparoscopy)

None

Sexual & Contraceptive History, Frequency of intercourse per month:

<1

2-3

4+

Not sexually active

Pain during intercourse?

Yes

No

History of STIs (e.g., Chlamydia, Gonorrhea)?

yes

no

unsure

Previous contraceptive use:

Birth control pills

IUD

Injectables (Depo-Provera)

None

Symptoms & Lifestyle. Do you experience any of these? (Check all that apply)

Excessive facial/body hair

Acne or oily skin

Hair loss/thinning

Milky nipple discharge

Hot flashes/night sweats

Pelvic pain outside periods

Do you smoke or drink alcohol?

Never

Occasioanlly

Regularly

Stress levels related to fertility:

Low

Moderate

High

Additional Notes. How long have you been trying to conceive?

<6 months

6-12 months

1-2 years

>2 years

Any other concerns?

Expert Fertility Assessment
Reviewed by Experienced Gynecologists & Fertility Specialists

Please fill in the following form. Your responses will be carefully reviewed by our team of specialist doctors, who will analyze your case in detail. A personalized fertility assessment report will be prepared and shared with you via email within 2 hours of submission. For urgent cases, please contact our clinic directly. +92 333 533 80 35

Thank you for completing this form. Your responses will be carefully reviewed by our team of specialist doctors, who will analyze your case in detail. A personalized fertility assessment report will be prepared and shared with you via email within 2 hours of submission. For urgent cases, please contact our clinic directly.