CRH | The Center for Reproductive Health

	Dr. Vasquez

	Accreditation

Fertility Self Evaluation

Men's and Women's Fertility Self Test. The following form is private and only used to evaluate if there is a fertility concern or no fertility concern. This is not a medical evaluation and results should be consulted with a qualified fertility specialist.

1. Have you been trying to conceive for more than one year?
a) Yes
b) No

2. Have you failed to conceive with artificial insemination?
a) Yes
b) No
c) Didn't have such treatment before

3. Are her tubes blocked?
a) Yes
b) No
c) Don't know

4. Has he had a vasectomy or have her tubes been tied?
a) Yes
b) No

5. Does he have an abnormal semen analysis?
a) Yes
b) No
c) Don't know

6. Does she have significant endometriosis or pelvic adhesions and are you trying to get pregnant?
a) Yes
b) No
c) Don't know

7. Has she been diagnosed with PCOS?
a) Yes
b) No

8. Have you failed treatments at other fertility clinics?
a) Yes
b) No

9. Are you ready for IVF?
a) Yes
b) No
c) Don't know

Self Evaluation Results Contact

First Name
Last Name
Email

Privacy: The information you are about to submit is confidential and will be kept private from any 3rd party. The information is only used for the CRH fertility self evaluation.