Infertility is caused by female-factors in about 50% of couples, male-factors in about 40%, and both male/female-factors in about 10%. Conditions such as endometriosis, uterine fibroids, or pelvic adhesions interfere with fertility, frequently through more than one mechanism.

As a first step in helping you overcome infertility, please complete the Endometrisois Infertility Consultation Form below.

First Name:
Last Name:
Address 1:
Address 2:
City:
If live in USA, what State:
Zipcode:
Country:
E-Mail Address:
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Phone:
Your Age:
Your Height:
Your Weight:
Specify any current treatment:
Prior treatments:
Do you have endometriosis:
How was it diagnosed:
When was it diagnosed:
How extensive was it:
How was it treated:
Who have you seen:
Results to date:
# years trying to get pregnant:
# children:
# miscarriages:
How old were you when you first menstruated:
# days usually between periods:
How long do periods last:
Any mid-cycle bleeding:
Date of last menstrual cycle:
Menstrual period pain level:
Do you have regular menstrual cycles:
Heavy or light menstrual flow:
Is Pap Smear within normal limits:
Is mammogram within normal limits:
Describe any family genetic abnormalities:
If appropriate, why were you excluded from donating blood:
Describe any surgeries:
Describe Alcohol and Drug usage:
Any dietary restrictions:
Any allergies:
Have you ever been told in the
past, that you have had any of the
following? (check all that apply):		 Abnormal Pap Smear
Hepatitis A, B, or C
Acne
Herpes
AIDS
High blood pressure
Allergies
Hypertension
Anemia
Intolerance to hot/cold
Alzheimer's Disease
Jaundice
Anorexia
Kidney Disease
Appendicitis
Loss of libido
Arthritis
Loss of scalp hair
Autoimmune Disorder
Measles
Colitis
Multiple Sclerosis
Blocked fallopian tubes
Neurologic problems
Breast Cancer
Nongonococcal Urethritis
Breast masses
Ovarian Cancer
Breast secretions
Ovarian Cysts
Bronchitis
Pain with intercourse
Cancer
Parasitic infections
Cervical Cancer
Pelvic Inflammatory Disease
Chlamydia
Pneumonia
Chronic cough
Polycystic Ovarian Syndrome (PCOS)
Chronic Pelvic Pain (CPP)
Poor sense of smell
Condyloma
Psychiatric care
Diabetes
Rheumatic Fever
Endocrine Disease
Scarlet Fever
Endometriosis
Seizures
Gonorrhea
Sexually Transmitted Disease (STD)
Epilepsy
Syphilis
Excessive hair growth
Thyroid problems
Excessive sweating
Transfusion problems
Excessive weight change
Tuberculosis
Fibroids
Ulcers
Dizziness
Ureaplasma/Mycoplasma
Frequent headaches
Vaginitis
Gallbladder Disease
Visual disturbances
Heart Disease
Depression
Schizophrenia
Obsessive-Compulsive Disorder
Self-mutilation

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