What is the fertility clinic intake form template?
A first fertility consultation goes further when the doctor already knows how long someone has been trying, what's happened in previous pregnancies or treatment, what their cycle is like, and their wider medical history. Gathering that in advance, with test results attached, lets the appointment focus on next steps.
This template starts with the patient's details and whether they're starting treatment with a partner or on their own. It then asks how long they've been trying, what they'd like help with — from investigations to IUI, IVF, egg freezing, donor treatment or fertility preservation — previous pregnancies and their outcomes, any earlier treatment, and uploads of results or summaries.
A cycle page, for patients with ovaries, covers periods, symptoms, diagnosed conditions and surgery. A medical page records other conditions, medicines, allergies, height and weight, smoking, alcohol and family history. For couples, a partner section adds their details, semen analysis status, medical history and smoking. Each intake is saved as a PDF in FileIt.
- Best for
- Fertility clinics, reproductive medicine units and gynaecology practices
- Filled in by
- The patient, before their first consultation
- Time to complete
- About 10 minutes
- Includes
- Treatment goals, pregnancy and treatment history with uploads, cycle questions, medical history, partner section and consent
Who uses a fertility clinic intake form?
- New patient packs sent before a first fertility consultation
- Couples starting investigations together
- Single patients or same-sex couples exploring donor treatment
- Patients considering egg freezing
- Fertility preservation referrals before cancer treatment
- Patients transferring from another clinic for a second opinion
Questions on this fertility clinic intake form
38 questions over 5 pages · includes file upload, conditional questions, multiple pages, consent checkbox.
1 About you
- Your name*
- Date of birth*
- Phone*
- Email*
- Pronouns (optional)
- Are you starting treatment with a partner?* Yes, with a partner · No, on my own
- How were you referred? Self-referral · GP or family doctor · Gynaecologist · Another fertility clinic · Other
- GP or family doctor and practice
2 Goals & history
- How long have you been trying to conceive?* Not trying yet · Less than 6 months · 6–12 months · 1–2 years · More than 2 years · Not applicable
- What would you like help with?* Finding out why we haven't conceived · IUI · IVF or ICSI · Egg freezing · Donor eggs or sperm · Fertility preservation before medical treatment · A second opinion
- Previous pregnancies (you)
- Outcomes of previous pregnancies asked only when it applies
- Have you had fertility treatment before?*
- Previous treatment* asked only when it applies
- Previous test results or treatment summaries
3 Cycle & reproductive health
- Your menstrual cycle* I have regular periods · My periods are irregular · I don't have periods · Not applicable
- First day of your last period asked only when it applies
- Usual cycle length asked only when it applies
- How irregular? asked only when it applies
- Do you have any of these? Very painful periods · Heavy bleeding · Bleeding between periods or after sex · Pain during sex · Excess hair growth or acne · None of these
- Diagnosed reproductive conditions PCOS · Endometriosis · Fibroids · Blocked or damaged tubes · Pelvic infection in the past · Low ovarian reserve · None
- Pelvic or gynaecological surgery
4 Medical history
- Other medical conditions
- Medicines and supplements
- Allergies
- Height and weight
- Do you smoke or vape?* No · I used to · Yes
- Alcohol None · Occasionally · A few drinks a week · Most days
- Family history worth mentioning
5 Partner & consent
- Partner's name* asked only when it applies
- Partner's date of birth* asked only when it applies
- Partner's email asked only when it applies
- Has your partner been involved in a pregnancy before? asked only when it applies
- Semen analysis asked only when it applies Done — results normal · Done — results not normal · Not done yet · Not applicable
- Partner's medical conditions, surgery and medicines asked only when it applies
- Does your partner smoke or vape? asked only when it applies No · Used to · Yes
- Questions for your first consultation
- Consent*
The fertility clinic intake form, page by page
1 About you
The patient gives their name, date of birth, phone, email and optional pronouns, says whether they're starting treatment with a partner or on their own, how they were referred and who their GP or family doctor is.
2 Goals & history
The patient says how long they've been trying to conceive and ticks what they'd like help with, such as investigations, IUI, IVF or ICSI, egg freezing, donor eggs or sperm, fertility preservation or a second opinion. They give the number of previous pregnancies — any number above zero opens a box for outcomes — and say whether they've had fertility treatment before, with details of clinic, treatment, cycles, medicines and outcomes. Up to five files of results or summaries can be uploaded.
3 Cycle & reproductive health
For patients with ovaries, this page asks whether periods are regular, irregular or absent. Regular cycles ask for the first day of the last period and usual cycle length; irregular ones ask how irregular. It then covers symptoms such as painful or heavy periods and pain during sex, diagnosed conditions including PCOS, endometriosis, fibroids and blocked tubes, and any pelvic surgery.
4 Medical history
The patient lists other medical conditions, medicines and supplements, and allergies, gives their height and weight, and answers questions on smoking and alcohol. A family history box covers things like early menopause or genetic conditions.
5 Partner & consent
When the patient has a partner, this page asks for the partner's name, date of birth and email, whether they've been involved in a pregnancy before, semen analysis status, their medical conditions, surgery and medicines, and whether they smoke. Everyone can add questions for the first consultation and agrees to the clinic using the information to prepare.
Make the template yours
- Add your clinic's test requirements, such as blood tests to book in advance, to the cover
- Send partners their own copy of the form if you prefer separate histories
- Add questions about funding route or insurance cover
- Adjust the treatment goals to the services you offer
- Add your privacy notice to the consent statement
- File each patient's intake in a vault folder only clinical staff can open
Tips for a better fertility clinic intake form
- Tell patients they can leave any question blank and discuss it in person
- Ask for previous clinic records early — they can take time to arrive
- Use inclusive wording that fits all the patients you see
- Review uploaded results before the consultation, not during it
- Follow up on smoking or alcohol answers kindly and without judgement
- Check medicines and supplements before prescribing fertility drugs
Every response becomes a PDF in your vault
Each intake is saved as a PDF in the vault folder you choose, with any uploaded results attached. The account owner can be emailed when a new patient submits, and the patient can receive a copy.
In Responses, filter by name or date to prepare for upcoming consultations, or export to CSV to see which treatments new patients are asking about.
- Start from this template. It opens in the FileIt Forms designer — change any question, add pages, set the rules for when questions appear.
- Share it. Turn on a public link, or send it to people by email, each with their own link. They don’t need a FileIt account.
- Get the answers as PDFs. Each response is saved as a PDF in the vault folder you choose, with uploaded files attached — and listed in a Responses table you can export to CSV.
Fertility clinic intake form: frequently asked questions
Is this fertility clinic intake template free?
Yes. It's part of the Forms app, included with every FileIt account, the free plan too.
Does the partner need to fill in a separate form?
No. If the patient says they're starting with a partner, a partner section appears at the end of the same form. You can also send partners their own copy if you prefer.
Is this form suitable for single patients or same-sex couples?
Yes. Patients choose whether they have a partner, the cycle page can be marked not applicable, and the goals include donor treatment.
Can patients upload previous test results?
Yes. Up to five PDF or image files can be attached on the goals and history page.
Do all questions have to be answered?
No. Only a few core questions are required. Patients can leave sensitive questions blank and talk them through at the consultation.
Who can see the answers?
Responses are filed in your FileIt vault. Keep them in a folder only your clinical team can open.