Patient Information
Patient Name
*
First Name
Middle Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Alternative Phone Number
-
Area Code
Phone Number
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
*
Occupation
Employer
S.S.#
*
Age
Birthdate
Height
Weight
*
Primary MD
OB-GYN
Partner Information
Partner Name
First Name
Middle Name
Last Name
Phone Number
-
Area Code
Phone Number
Alternative Phone Number
-
Area Code
Phone Number
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
Employer
S.S.#
Age
Birthdate
Height
Weight
Insurance Information
*If you select 'Yes', please complete all of the insurance fields below
Do you have Insurance
*
Yes
No
Please provide your card as we will need a copy (Front/Back) for your chart.
Front of Insurance Card
Back of Insurance Card
Insurance Company
Subscriber
Birthdate
Group#
Policy/Member ID
Insurance Type
PPO
HMO
POS
EPO
Partner Covered
Yes
No
Medical Group (if applicable)
Secondary Insurance/Partner Insurance
Please provide your card as we will need a copy (front/back) for your chart.
Do you have secondary/partner Insurance
*
Yes
No
Front of Insurance Card
Back of Insurance Card
Insurance Company
Subscriber
Birthdate
Group#
Policy/Member ID
Insurance Type
PPO
HMO
POS
EPO
Partner Covered
Yes
No
Medical Group (if applicable)
Emergency Contact
*
First Name
Last Name
Relationship
Phone Number
*
-
Area Code
Phone Number
Patient Signature
*
Clear
Female Medical History & Information
Reason for your visit
*
Fertility Evaluation
Fertility Preservation
Fertility Treatment
Pregnancy History- Please fill out each of your pregnancies below. Write N/A in box 1 if not applicable.
Year Conceived?
How long to Conceive?
Current Partner Y/N?
Fertility Treatment used?
Type? Vaginal C-Section D&C Abortion Miscarriage
1.
2.
3.
4.
5.
6.
Have you had prior fertility testing or treatment?
Yes
No
If Yes check all that apply:
Clomiphene with natural intercourse
Clomiphene with insemination (IUI)
Injectable medications with natural intercourse
Injectable mediacations with intrauterine insemination (IUI)
In vitro fertilization (IVF)
Donor or Recipient
Frozen Embyro Transfter (FET)
Surrogacy
Date of last menstrual cycle:
How old were you when you had your first period:
How many periods do you have yearly:
Average number of days between periods:
Do you have severe cramping or pelvic pain with your period:
Average number of days of bleeding:
What medication have you used to start a period (write N/A if not applicable)?:
Are your periods (check all that apply):
Absent
Regular
Light
Heavy
Spotting BEFORE periods
Spotting BETWEEN periods
Irregular
Surrogacy
Female Sexual History
Have you used over- the counter ovulation kits to time intercourse?
Yes
No
How often do you have intercourse?
Do you have pain with intercourse?
Yes
No
Do you use lubricants (KY Jelly, etc.) during intercourse?
Yes
No
If yes what brand/type of lubricant?
Have your every used contraceptives?
Yes
No
If yes what brand/type of contraceptive?
Have you ever had any of the following sexually transmitted diseases or pelvic pain? Check all that apply:
Chlamydia
Gonorrhea
Syphillis
Genital Warts/HPV
Hepatitis
Herpes
HIV/AIDS
PID
No sexually transmitted diseases
Female Medical History
Do you have any current, chronic medical conditions (IE: diabetes, high blood pressure, etc.)?
Yes
No
If yes what type?
Are you currently taking any prescribed medications?
Yes
No
If yes, please list
Are you currently taking any over-the- counter or herbal medications?
Yes
No
If yes, please list
Are you allergic to any medications?
Yes
No
If yes, please list
Any additional information you would like to share about your medical history?
Female Surgical History
Female Surgical History- Please fill out each of your surgeries below. Write N/A in box 1 if not applicable.
Year of Surgery?
Physician?
What type of surgery?
Complications?
1.
2.
3.
4.
5.
6.
Do you have any problems with anesthesia?
Yes
No
If yes please describe?
Female Social History
Do you smoke cigarettes?
Do you drink alcohol?
Do you use Marijuana, cocaine, or other similar drug?
Do you exercise?
Yes
No
If yes, how many times per week?
Any additional information you would like to share?
Female Family Ancestry
What is your ancestry? Check all that apply:
African-American
American Indian/Native American
Ashkenazi Jewish
Asian-American
Cajun/French Canadian
Caucasian
Eastern European
Hispanic/Latino
Northern European
Southern European
Does anyone in your immediate family have a history of a medical condition? (ie: Diabetes, Cancer, High Blood Pressure, Autism, etc) Write N/A if not applicable
Do you have a family history of the following genetic diseases ?
Cystic Fibrosis
Sickle Cell
Tay Sachs
Thalasemia
None that I am aware of
Any additional information you would like to share?
Male Medical History & Information
Medical History
Do you have a Male partner
*
Yes
No
Have you been evaluated by an urologist?
Yes
No
Have you had a semen analysis?
Yes
No
Do you have retrograde ejaculation of sperm into the bladder?
Yes
No
Do you have difficulty with erections?
Yes
No
If yes please describe?
Have you had a vasectomy?
Yes
No
If yes, when was your vasectomy?
Have you had a reversal? (Yes/No?, Date if yes)
Have you been exposed to radiation or harmful chemicals?
Yes
No
If yes please describe?
Have you been diagnosed with cancer?
Yes
No
If yes please describe?
Have you had chemotherapy for cancer?
Yes
No
Do you have any current chronic medical conditions (IE: diabetes, blood pressure, etc.)?
Yes
No
If yes please describe?
Are you currently taking any PRESCRIBED medications?
Yes
No
If yes please list?
Are you currently taking any over the-counter medications?
Yes
No
If yes please list?
Are you currently taking any over the-counter herbal medications?
Yes
No
If yes please list?
Are you allergic to any medications?
Yes
No
If yes what type?
Are you allergic to any foods?
Yes
No
If yes please list?
Are you allergic latex?
Yes
No
Are you iodine?
Yes
No
Any additional information you would like to share?
Male Sexual History
Have you previously conceived with another woman?
Yes
No
Have you ever had any of the following sexually transmitted diseases or pelvic pain? Check all that apply:
Chlamydia
Gonorrhea
Syphillis
Genital Warts/HPV
Hepatitis
Herpes
HIV/AIDS
No sexually transmitted diseases
Male Social History
Do you smoke cigarettes?
Do you drink alcohol?
Do you use Marijuana, cocaine, or other similar drug?
Do you exercise?
Yes
No
If yes, how many times per week?
Any additional information you would like to share?
Male Family Ancestry History
What is your ancestry? Check all that apply:
African-American
American Indian/Native American
Ashkenazi Jewish
Asian-American
Cajun/French Canadian
Caucasian
Eastern European
Hispanic/Latino
Northern European
Southern European
Any additional questions you would like to address at your appointment?
Submit
Should be Empty: