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Description
Question 1:
How old are you?
Under 35
35 - 39 years old
40+ years old
Question 2:
How long have you been trying to get pregnant?
Less than 6 months
6-12 months
Over 12 months
Question 3:
Are you presently taking a Folic acid supplement or prenatal vitamins?
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No
Question 4:
Do you have regular menstrual cycles?
Yes
No
Don't Know
Question 5:
Are you ovulating regularly?
Yes
No
Don't Know
Question 6:
Does he have a normal sperm count?
Yes
No
Don't Know
Question 7:
Do you presently take medications (OTC or otherwise)?
Yes
No
If you answered 'YES' please explain:
Question 8:
Have you previously had pelvic or gynecologic surgery?
Yes
No
If you answered 'YES' please explain:
Question 9:
Rubella (German Measles)
Tested and Immune
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Tested and Not Immune
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W 3 C
11/21/2009 00:06
