ASRM Infertility History Form

In an effort to more efficiently evaluate you, we request that you print and complete this evaluation form and bring it with you to your initial appointment. This form was designed by the American Society of Reproductive Medicine to ascertain any information in your personal history which might help us determine how to best individualize your treatment.

We request that you also obtain any medical records that are relevant to your treatment with us, and bring them with you to your appointment, or you may fax them to us at (773) 702-5848. We look forward to seeing you and becoming involved in your care.