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New Patient Forms
Patient Infertility History Questionnaire

Patient Infertility History Questionnaire

Please complete and return 5-7 Business days prior to your appointment

1 INFORMATION

2MEDICAL

3MALE MEDICAL

CONTACT INFORMATION
Primary Patient (Female)
First Name*
Last Name*
Age*
Date of Birth (MM/DD/YY)*

MM slash DD slash YYYY
Occupation
Home Street Address*
City*
State*
Zip/Postal Code
Country*
Indicate which number to call or leave messages;
Phone (Home)
Phone (Work)
Phone (Cell)*
E-mail*
Are you married?
- Yes
- No
- Divorced
- Other
If other
Spouse/Partner
First Name*
Last Name*
Age*
Date of Birth (MM/DD/YY)*

MM slash DD slash YYYY
Occupation
Home Street Address*
City*
State*
Zip/Postal Code
Country*
Physician Notes (For office use only)
By whom were you referred?
- Physician
- Former Patient/Friend/Relative
- Web Site
- Insurance
Physician Name*
Phone*
Address*
Name
Website URL
Name of Insurance
Who is your Ob/Gyn?
Name*
Phone*
Address*
Who is your Ob/Gyn?
Name*
Phone*
Address*

FEMALE MEDICAL HISTORY AND INFORMATION
Primary Patient
Reason for Visit
- Infertility Evaluation
- Sperm Insemination
- Other
Reason for Visit (Other)
What are your expectations for this visit?
Any questions you wish to address
Do you have any personal, ethical, or relations objections to any of our tests or treatments such as insemination, in vitro fertilization, egg donation, sperm donation, masturbation to collect a semen sample, etc.?
- Yes
- No
If Yes*
How many months have you been having intercourse without using any form of birth control?
Pregnancy History
Number of ALL Pregnancies
Number of Miscarriages (less than 20 weeks)
Number of Ectopic / Tubal Pregnancies
Number of Elective Terminations (Abortions)
Number of Full Term Deliveries
Of these, how many were live births?
How many were stillborn?
Number of Premature (less than 37 weeks) Deliveries
Of these, how many were live births?
How many were stillborn?
Any Pregnancies with Birth Defects?
- Yes
- No
If Yes
Date Pregnancy Ended or delivered
Months to Conception
Treatments to Conceive
Deliver Type/D&C Complications
Current Partner?
- Yes
- No
Menstrual Cycle History
Menstrual cycle pattern (check all that apply):
- Regular periods
- Irregular periods
- Spotting before periods
- No periods
- Heavy periods
- Light periods
- Bleeding between periods
Number of days between the start of one period to the start of the next period
How many days of bleeding do you have?
Dates of the 1st day of your last 2 menstrual periods
Age when you had your first period
Age when you first noticed: Breast development (years)
How many periods do you have per year?
Do you need medication to bring on a period?
- Yes
- No
If Yes
If you do not have periods, at what age did you stop having them?
Do you have server cramping or pelvic pain with your periods?
- Yes
- No
Always __ Sometimes __ Recently __In the past
Contraceptive Methods (History)
History
- None
- Condoms
- Diaphragm
- IUD
- Birth control pills
- Never used birth control pills
- Inject able contraception
- Skin patch
- Foam or Jelly
- Tubal sterilization procedure (tubes tied)
- Tubes untied
Did your mother take DES when she was pregnant with you?
- Yes
- No
- Don’t know
Sexual History
How many times do you have intercourse per week?
Have you used over-the-counter ovulation kits to time intercourse
- Yes
- No
Do you have pain with intercourse?
- Yes
- No
Do you use lubricants (K-Y Jelly*, etc.) during intercourse?
- Yes
- No
what types?
Have you had any of the following sexually transmitted diseases or pelvic infections?
- Yes
- No
If Yes (check all that apply)
- Chlamydia
- Gonorrhea
- Herpes
- Genital warts/HPV
- Syphilis
- HIV/AIDS
- Hepatitis
- Other
Pap Smear Medical History
When was your last pap smear (month end year ) ?
- Normal
- Abnormal
When was your last abnormal pap smear?
Have you undergone any procedures as a result of an abnormal pap smear?
- Yes
- No
Yes (check all that apply)
- Colposcopy
- Cryosurgery (Freezing)
- Laser treatment
- Conization [ ]LEEP procedure
Breast Screening History
Have you ever had a mammogram?
- Yes
- No
Date

MM slash DD slash YYYY
Result
- Normal
- Abnormal
Medical History
Are you allergic to any medications?
- Yes
- No
Please list and describe reactions
Are you allergic to any foods (peanuts, eggs, etc.)?
- Yes
- No
Please list and describe reactions
* List any medications you are currently taking, including over the counter medicines .
Do you take any herbal medicines/vitamins or health food store supplements?
- Yes
- No
Please list and describe reactions
Do you have any medical problem(s)?
- Yes
- No
Please list type, dates, and treatments.
Did you have either of these childhood illnesses?
- Chickenpox (Varicella)
- German Measles (Rubella)
- Don’t know
- Other childhood diseases
If Other childhood diseases
Vaccinations
Chickenpox (Varicella)
- Yes
- No
- Don’t know
MMR – Measles, Mumps, and Rubella (German Measles)
- Yes
- No
- Don’t know
BCG (Tuberculosis)
- Yes
- No
- Don’t know
Hepatitis B
- Yes
- No
- Don’t know
Polio
- Yes
- No
- Don’t know
Influenza
- Yes
- No
- Don’t know
Social History
How many caffeinated beverages (coffee, tea, soda) do you drink per day?
Do you smoke cigarettes?
- Yes
- No
How many/day?
Quit – when?
Do you drink alcohol?
- Yes
- No
If you drink alcohol
- Beer – # per week
- Wine – # per week
- Liquor – # per week
Do you use marijuana, cocaine, or any other similar drug?
- Yes
- No
If Yes please describe
Do you exercise?
- Yes
- No
Are you aware of any radiation exposures other than X-rays?
- Yes
- No
Describe
Physician Notes (for office use only)
Surgical History
Have you had any surgeries?
- Yes
- No
List all surgeries in chronologic order
Did you have any anesthesia problems?
- Yes
- No
Describe
Physical Symptoms
General
- Diabetes
- Hair loss
- Anorexia/Bulimia
- Lack of energy
- Fever/chills
- Other
- None
If Other (Describe)
Head, Eyes, Ears, Nose, and Throat
- Dizziness
- Loss of sense of smell
- Headaches
- Chronic nasal congestion
- Blurred vision
- Ringing ears
- Hearing loss/deafness
- Other
- None
If Other (Describe)
Respiratory
- Shortness of breath
- Asthma
- Bronchitis
- Pneumonia
- Tuberculosis
- Bloody cough
- Other
- None
If Other (Describe)
Endocrine/Hormonal
- Recent weight gain or loss
- Thyroid gland problems
- Rapid weight gain or loss
- Excessive hunger/thirst
- Temperature intolerance-hot flashes or feeling cold
- Other
- None
If Other (Describe)
Breasts
- Discharge
- Lumps
- Abnormal mammogram
- Reduction
- Augmentation/Breast Implants
- Other
- None
If Other (Describe)
Neurological Problems
- Weakness/Loss of balance
- Seizures/Epilepsy
- Headaches
- Migraine headaches
- Numbness
- Memory Loss
- Other
- None
If Other (Describe)
Gastrointestinal
- Nausea/Vomiting
- Ulcers
- Hepatitis
- Diarrhea
- Blood in your stools
- Irritable Bowel Syndrome
- Change in bowel habits
- Colitis (ulcerative or Cohn’s)
- Other
- None
If Other (Describe)
Genito-Urinary
- Bladder infections
- Kidney infections
- Vaginal infections
- Frequent urination
- Blood in the urine
- Leaking Urine
- Herpes
- Other
- None
If Other (Describe)
Skin/Extremities
- Unexplained rash/inflammation
- Acne
- Skin caner
- Burn injury
- Moles changing in appearance
- Excess hair growth
- Other
- None
If Other (Describe)
Musculoskeletal
- Unusual muscle weakness
- Decreased energy/stamina
- Rheumatoid arthritis
- Lupus Erythematosus
- Myasthenia gravis
- Other
- None
If Other (Describe)
Hematologic
- Blood clotting disorder/Blood clot
- Sickle Cell Anemia
- Thrombophlebitis
- Easy bruising
- Swollen glands/lymph nodes
- Blood transfusions
- Other
- None
If Other (Describe)
Cardiovascular
- Palpitations/Skipped beats
- Chest pain
- Heart attack
- Stroke
- Murmurs
- High blood pressure
- Rheumatic fever
- Mitral valve prolapse
- Other
- None
If Other (Describe)
Family History
Mother (Living)
- Yes
- No
Age*
Cause of Death/Age at Death*
Father (Living)
- Yes
- No
Age*
Cause of Death/Age at Death*
Brother (s) (Living)
- Yes
- No
Age*
Cause of Death/Age at Death*
Sister (s) (Living)
- Yes
- No
Age*
Cause of Death/Age at Death*
Maternal Grandmother (Living)
- Yes
- No
Age*
Cause of Death/Age at Death*
Maternal Grandfather (Living)
- Yes
- No
Age*
Cause of Death/Age at Death*
Paternal Grandmother (Living)
- Yes
- No
Age*
Cause of Death/Age at Death*
Paternal Grandfather (Living)
- Yes
- No
Age*
Cause of Death/Age at Death*
What is your Ancestry?
- African – American
- Amer.Indian/NativeAmer
- Ashkenazi Jewish
- Asian-American
- Cajun/French Canadian
- Caucasian
- Eastern European
- Hispanic – American
- Northern European
- Southern European
- Other
Disorders in Your Family
Breast cancer
- Yes
- No
- Don’t Know
If Yes*
Ovarian cancer
- Yes
- No
- Don’t Know
If Yes*
Other cancer
- Yes
- No
- Don’t Know
If Yes*
Diabetes
- Yes
- No
- Don’t Know
If Yes*
Thyroid Problems
- Yes
- No
- Don’t Know
If Yes*
Heart Disease
- Yes
- No
- Don’t Know
If Yes*
Blood Clots
- Yes
- No
- Don’t Know
If Yes*
Obesity
- Yes
- No
- Don’t Know
If Yes*
Psychiatric problems
- Yes
- No
- Don’t Know
If Yes*
Tuberculosis
- Yes
- No
- Don’t Know
If Yes*
Endometriosis
- Yes
- No
- Don’t Know
If Yes*
Infertility
- Yes
- No
- Don’t Know
If Yes*
Menopause before age 40
- Yes
- No
- Don’t Know
If Yes*
Birth Defects
- Yes
- No
- Don’t Know
If Yes*
Cystic Fibrosis
- Yes
- No
- Don’t Know
If Yes*
Tay-Sachs disease
- Yes
- No
- Don’t Know
If Yes*
Canavan disease
- Yes
- No
- Don’t Know
If Yes*
Bloom Syndrome
- Yes
- No
- Don’t Know
If Yes*
Gaucher disease
- Yes
- No
- Don’t Know
If Yes*
Neimann-Pick disease
- Yes
- No
- Don’t Know
If Yes*
Fanconi Anemia
- Yes
- No
- Don’t Know
If Yes*
Familiar Dysautonia
- Yes
- No
- Don’t Know
If Yes*
Muscular Dystrophy
- Yes
- No
- Don’t Know
If Yes*
Neurologic brain/spine
- Yes
- No
- Don’t Know
If Yes*
Neural Tube Defects
- Yes
- No
- Don’t Know
If Yes*
Bone/Skeletal Defects
- Yes
- No
- Don’t Know
Bone/Skeletal Defects
- Yes
- No
- Don’t Know
If Yes*
Dwarfism
- Yes
- No
- Don’t Know
If Yes*
Developmental Delay
- Yes
- No
- Don’t Know
If Yes*
Learning problems
- Yes
- No
- Don’t Know
If Yes*
Polycystic kidneydisease
- Yes
- No
- Don’t Know
If Yes*
Marfan syndrome
- Yes
- No
- Don’t Know
If Yes*
Hemophilia
- Yes
- No
- Don’t Know
If Yes*
Sickle Cell anemia
- Yes
- No
- Don’t Know
If Yes*
Thalassemia
- Yes
- No
- Don’t Know
If Yes*
Galactosemia
- Yes
- No
- Don’t Know
If Yes*
Deafness/Blindness
- Yes
- No
- Don’t Know
If Yes*
Color/Blindness
- Yes
- No
- Don’t Know
If Yes*
Hemochromatosis
- Yes
- No
- Don’t Know
If Yes*
None of the above
- Yes
- No
- Other
PRIOR INFERTILITY TESTING AND TREATMENT
*Have you had prior infertility testing or treatment elsewhere?
- Yes
- No
Prior Tests (check all that apply):
- Basal body temperature chart
- Thyroid test
- Ovulation test
- Day 3 blood test for FSH level
- Hysterosalpingogram (HSG)
- Laparoscopy
- Hysteroscopy surgery
- Progesterone blood test
- Prolactin blood test kit
Date*

DD slash MM slash YYYY
Results*
Prior Treatment (Check all that apply):
- Intrauterine insemination
- Clomiphene citrate with timed intercourse Maximum # tablets per day?
- Clomiphene citrate with insemination Maximum # tablets per day?
- Daily fertility drug injections with insemination: Maximum # vials per day?
- Completed in vitro fertilization cycle(s)
- Frozen embryo transfers)
Of cycles
Dates
Outcome
Any other prior treatment (describe)
* Additional Information/Complications:
EMOTIONAL STATUS
* On a scale of 1-10 (10 being the worst), estimate the level of stress you feel due to infertility and other pressures.
* Do you see a counselor?
- Yes
- No
For how long
How often?
List any anti-depressant/anti – anxiety medications you are currently taking?
Describe any emotional, marital, or sexual problems caused by your infertility
I confirm that I have reviewed the information above:
PATIENT'S SIGNATURE*
PHYSICIAN'S SIGNATURE*
Date(Patient)*

MM slash DD slash YYYY
Date(Physician)*

MM slash DD slash YYYY

Complete with your male partner if applicable
List your current medications
List any current medical problem(s)
How many caffeinated beverages (coffee, tea, soda) do you drink per day?
Do you smoke cigarettes?
- Yes
- No
- Quit
How many/day?
How many/day?
When
Do you drink alcohol?
- Yes
- No
Liquor
- Beer
- Wine
- Liquor
Per week
Do you use marijuana, cocaine, or any other similar drug?
- Yes
- No
Describe
Do you exercise?
- Yes
- No
Describe
* Are you aware of any radiation exposures other than X-rays?
- Yes
- No
Describe
Physician Notes (for office use only)
Have you been evaluated by a urologist?
- Yes
- No
Have you previously conceived with another woman?
- Yes
- No
How many times?
Birth control used?
- Yes
- No
Have you had a semen analysis?
- Yes
- No
Do you have difficulty with erections?
- Yes
- No
Do you have retrograde ejaculation of sperm into the bladder?
- Yes
- No
Have you had any of the following sexually transmitted diseases or pelvic infections?
- Yes
- No
chalmydia/gonoeehea
- Chlamydia
- Gonorrhea
- Herpes
- Genital warts/HPV
- Syphilis
- HIV/AIDS
- Hepatitis
- Other
Date

MM slash DD slash YYYY
Other
Have you had a history of undescended testicles?
- Yes
- No
One side
Both
Do you have scrotal or testicular pain?
- Yes
- No
Did you have the mumps after puberty?
- Yes
- No
Have you had prior injury to your testicles requiring hospitalization?
- Yes
- No
Have you had any fever in the last 3 months?
- Yes
- No
Have you been diagnosed with any of the following diseases?
- Diabetes Mellitus
- Cancer
- Multiple Sclerosis
- Prostatic infections
- Urinary infections
- High Blood Pressure
Any medications?
Have you had a vasectomy?
- Yes
- No
have you had a vasectomy reversal?
- Yes
- No
Date

MM slash DD slash YYYY
Have you had surgery for varicocele repair?
- Yes
- No
you had hernia surgery?
- Yes
- No
Did you undergo any bladder or penis surgery as a child?
- Yes
- No
Are you exposed to prolonged heat in the workplace?
- Yes
- No
Are you exposed to any radiation or harmful chemicals in the workplace?
- Yes
- No
Have you had chemotherapy for cancer?
- Yes
- No
You allergic to any medications?
- Yes
- No
Please list and describe reactions
Disorders in Your Family
Cystic Fibrosis
- Yes
- No
- Don’t know
Tay-Sachs disease
- Yes
- No
- Don’t know
Canavan disease
- Yes
- No
- Don’t know
Bloom syndrome
- Yes
- No
- Don’t know
Gaucher disease
- Yes
- No
- Don’t know
Neimann-Pick disease
- Yes
- No
- Don’t know
Fanconi Anemia
- Yes
- No
- Don’t know
Familiar Dysautonia
- Yes
- No
- Don’t know
Muscular Dystrophy
- Yes
- No
- Don’t know
Paternal Grandmother
- Yes
- No
- Don’t know
Paternal Grandfather
- Yes
- No
- Don’t know
Neurologic brain/spine
- Yes
- No
- Don’t know
Neural Tube Defects
- Yes
- No
- Don’t know
Neural Tube Defects
- Yes
- No
- Don’t know
Bone/Skeletal Defects
- Yes
- No
- Don’t know
Dwarfism
- Yes
- No
- Don’t know
Developmental Delay
- Yes
- No
- Don’t know
Learning problems
- Yes
- No
- Don’t know
Polycystic kidney disease
- Yes
- No
- Don’t know
Heart defect from birth
- Yes
- No
- Don’t know
Down syndrome
- Yes
- No
- Don’t know
Other chrom. defects
- Yes
- No
- Don’t know
Marfan syndrome
- Yes
- No
- Don’t know
Hemophilia
- Yes
- No
- Don’t know
Sickle Cell Anemia
- Yes
- No
- Don’t know
Thalassemia
- Yes
- No
- Don’t know
Galactosemia
- Yes
- No
- Don’t know
Deafness/Blindness
- Yes
- No
- Don’t know
Hemochromatosis
- Yes
- No
- Don’t know
Other
I confirm that I have reviewed the information above
SPOUSE/MALE PARTNER'S SIGNATURE*
PHYSICIAN'S SIGNATURE*
Date(Male Partner)*

MM slash DD slash YYYY
Date(Physician)*

MM slash DD slash YYYY
Physician Notes (for office use only)
Date

MM slash DD slash YYYY
Comments

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Coastal Fertility Medical Center offers one of the most affordable fertility treatments and is completely transparent regarding the costs of procedures and any other expenses that you may have to pay before commencing your treatment. This differentiates us from some fertility clinics that reduce prices before the signing of the contract but charge you extra later on. We make sure our patients are well aware of any possible extra pricing that may occur over the course of their treatment.

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Embryo Transfer

Following the Preimplantation Genetic Screening process, which helps ensure there are normal chromosome numbers and detects possible genetic disorders, the most healthy embryo(s) are selected to be implanted into your or your chosen surrogate’s womb. 2 weeks after the transfer of the embryo, your physician will conduct a final blood test to determine the level of hCG (human chorionic gonadotropin) in your body. Increased hCG levels usually indicate a positive pregnancy test.

Fertilization

For fertilization to take place, the collected egg and sperm are combined in a petri dish and cultured in an embryo incubator. This dish is closely watched to check whether any of the eggs have been fertilized. Once the egg is fertilized, it is referred to as an embryo or a blastocyst on the 5th day of development. Our in-house embryologist carefully nurtures every embryo to the right time, even if it means working outside the standard business operating hours. For instance: If an oocyte is not mature, our laboratory will wait for it to mature and then ICSI it at the right time.

Egg Retrieval & Sperm Collection

The egg retrieval is a slightly invasive medical procedure that takes about 20 to 30 minutes. You will be given an anesthetic to make you sleep for the duration of the procedure. Using ultrasound technology, your doctor will harvest your eggs transvaginally with a small, hollow needle connected to an ultrasound probe. Once your eggs are collected, your partner’s semen or donor sperm you have pre-selected is used for fertilization. The sperm are washed and prepared, and the top-quality sperm extracted is used to fertilize the eggs.

Ovarian Stimulation

Your doctor will create a customized medication schedule that contains information about the fertility medications and hormone injections you have to take. Medication and injections are taken to encourage your ovaries to mature a large number of eggs for fertilization. Since women don’t respond to fertility drugs and hormones the same way, personalized protocols are crucial to the IVF cycle success. At Coastal Fertility, we will monitor you closely, letting you understand the changes occurring in your body and keeping track of how your egg follicles are growing.

Fertility Evaluation

On-site consultations typicallyinclude a standard fertility evaluation, consisting of a physical examination, complementary follicular ultrasound, and testing to enable your doctor to know your present fertility status and draw up a treatment plan.

Initial Consultation

This consultation includes a detailed medical evaluation with a doctor. You and your physician will review your health records and have enough time to talk about your goals and get answers to your questions. We recommend that you jot down all your questions before the visit to allow you to make the best use of the time spent with your doctor.

Plan of Care Creation

Your Reproductive Endocrinologist will take all factors into consideration and create a comprehensive plan of care, otherwise known as the treatment plan. This plan will include treatment recommendations from the physician and enable your financial coordinator to make a precise quotation once you meet.

Superior Expertise

Our globally respected team of specialists are helping improve IVF technologies to enter into a generation of better outcomes for infertility. Although you’ll have a doctor guiding you, you are also going to benefit from the experience and insights of other doctors during case review collaboration meetings, which take place every week. So, you won’t just rely on the expertise of a specialist but benefit from the knowledge of many reputed fertility experts.

A One-stop Model

The infertility industry is currently segmented, with each service or treatment being handled by a different provider. Our all-inclusive model simplifies an otherwise complex and difficult process. We are here to revolutionize the infertility industry by offering a one-stop-service model to assist our patients through infertility challenges while reducing physical, emotional, and financial risks.

LGBT friendly

Our fertility clinic focuses on helping you build your family regardless of your sexual orientation or the gender you choose to identify with. We are even taking further steps to make LGTB people feel more welcome at our fertility clinic. Each of our patient-facing staff goes through LGTB training to let family-building clinicians provide necessary support and make you feel highly welcome.

Personalized Solutions

We know that every situation is different and that everyone requires different treatments. Unlike facilities that take “a one-size-fits-all” approach for all cases, our fertility specialists use more than 40 customized protocols to raise the chances of success. The customized approach even extends to our fertility laboratory. Our on-site lab director and his highly-experienced team nurture every embryo and egg to increase the odds of success of each cycle.

Specialized in Difficult Cases

Our team specializes in difficult cases and help patients who may have been considered “hopeless” at other fertility clinics. Thanks to our personalized solutions, expertise, and internal collaboration, weare able to maximize pregnancy success rates that are well above the industry average, even in difficult infertility cases.

Welcome

Upon your arrival, you will check in with a Patient Care Coordinator. We will obtain your insurance information for benefits verification, a copy of your identification and take a picture for your electronic medical chart

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