Infertility History Form
What an infertility history form asks, with sample questions on trying to conceive, pregnancies, periods, and health.
An infertility history form records time spent trying to conceive, past pregnancies, periods, birth control, medical history, and lifestyle before a fertility evaluation. It's also called a female patient history.
Infertility history form, handled by the AI Doctor avatar
AI Doctor, a real-time AI healthcare assistant avatar, asks the questions on an infertility history form in the patient's own language, strictly following the practice's instructions.
- Intake before the visit. Patients answer online before they arrive, or at a kiosk when they check in.
- Answers ready for the clinician. Clinicians see what the patient said before the visit starts.
- Less workload at the front desk. Staff spend less time handing out forms and entering answers by hand.
- Key details at a glance. The care team sees what matters up front and decides who needs attention first.
The form becomes a natural conversation: patients answer by talking, in their own words. AI Doctor is an information and patient-assistance interface. It collects answers for the care team to review. It doesn't diagnose, triage, or give treatment advice.
Sample infertility history form questions
Typical questions, written out so you can see the level of detail. Every practice words its own form differently.
- How many months have you been trying to conceive?Conception attempts
- Have you used ovulation kits to time intercourse?Conception attempts
- How many full-term deliveries have you had?Pregnancy history
- How many months did each pregnancy take to conceive?Pregnancy history
- How many periods do you have per year?Menstrual history
- Do you need medication to bring on a period?Menstrual history
- Which birth control methods have you used, and when?Contraceptive history
- Why did you stop each method?Contraceptive history
- Do you take herbal medicines or supplements?Medical history
- Have you had the chickenpox or MMR vaccine?Medical history
- Do you exercise, and how often?Social history
- Have you been exposed to radiation besides X-rays?Social history
These are examples to read, not a form to fill in.
Infertility history form: FAQ
What does an infertility history form ask?
The sample questions on this page are based on the ASRM Infertility History Form and UC Health's Female Patient History Form. This page groups them into six areas: conception attempts, pregnancy history, menstrual history, contraceptive history, medical history, and social history.
Who fills in an infertility history form, and when?
The patient, before the visit. The ASRM form asks patients to complete it and bring it to their scheduled visit.
Does an infertility history form cover a partner?
The ASRM form has three parts: contact details, the patient's own medical history, and a partner's medical history section, if that applies.
Is it the same as a female patient history?
Largely. UC Health's Center for Reproductive Health calls its version a Female Patient History Form, with the same pregnancy, menstrual, and medical sections.
Does it ask about vaccinations?
Yes. The ASRM form asks about chickenpox, MMR, hepatitis A and B, polio, tetanus, influenza, and other vaccines, with dates when known.
What happens after the form is completed?
A physician reviews it. The ASRM form leaves space on each page for the physician's notes.
Does AI Doctor give medical advice?
No. It collects information for the care team. It doesn't diagnose, triage, or recommend treatment.
Can patient answers stay on our own servers?
Yes. RAVATAR offers on-prem deployment: the platform can run inside your own perimeter, so patient answers stay there. RAVATAR complies with GDPR and the EU AI Act.
Set up your AI Doctor in Genesis AI Avatar Studio
Genesis AI Avatar Studio is where you set up, test, and publish AI avatars for your website, mobile app, or Holobox. No coding or technical skills needed.
- 01Choose the AI Doctor avatar.
- 02Add your practice's FAQs and visit information.
- 03Talk to it, then publish it.
