Fertility Preservation Intake Form

Name:
DOB:
Date:

Who referred you to our practice?

Reason for consultation:
What are your goals or expectations for your consultation?

Demographic Information:

Occupation:
Current weight: pounds
Height: feet inches

Ethnicity:

Medical History:

How old were you when your periods first started? years
Did you develop regular monthly periods at that time?
Do you have monthly menstrual periods now?
If yes, what is the usual number of days between the start of one period to the start of the next period? days
Dates of the 1st day of your last 2 menstrual periods: / / / / / /
How many menstrual periods do you have per year?
Do you have severe cramping or pelvic pain with your menstrual periods?
Do you have pain with intercourse?
Have you been diagnosed with endometriosis?
2 5 0 0 H o s p i t a l D r i v e , B u i l d i n g 7 , M o u n t a i n V i e w , C A 9 4 0 4 0650-325-N O V A ( 6 6 8 2 ) n o v a i v f . c o m
Have you ever had a pelvic infection?
Have you ever had any of the following sexually transmitted diseases or pelvic infections?
When was your last pap smear (month/year)? /
When was your last pap smear (month/year)? /
Do you perform self breast exams?
Have you ever had a mammogram?
When was your last mammogram? month year

Pregnancy History:

Pregnancy 1st 2nd 3rd 4th
Mo/Yr of conception
How long did it take to conceive?
Infertility treatment? (Y/N)
Did your current partner sire the pregnancy?
Outcome (vaginal delivery, cesarean, ectopic, miscarriage, termination)
Live birth > 37 weeks?(Y/N)
Other pregnancy complications?

Prior Fertility Treatment:

Have you been treated for infertility before?
If yes, where did you receive care and who was your physician?
What cause of infertility was diagnosed?

(If applicable):

Number of prior Fresh IVF Cycles
Number of prior Frozen IVF Cycles
2 5 0 0 H o s p i t a l D r i v e , B u i l d i n g 7 , M o u n t a i n V i e w , C A 9 4 0 4 0650-325-N O V A ( 6 6 8 2 ) n o v a i v f . c o m

Please complete the following table as accurately as possible, especially the “Physician/Clinic” column.

Test Date(s) Physician/Clinic Results/Findings
Thyroid Test (TSH)
Day 3 blood test for FSH/Estrogen
AMH
Prolactin level
Hysterosalpingogram (X-Ray of Tubes/HSG)
Sonohysterography (water ultrasound)
Hysteroscopy
Genetic Testing

Surgical History:

Please list any surgeries you have had in chronological order:

Year Reason and Type of Surgery

Medications/Supplements:

Are you allergic to any medications?

Are you currently taking any medications or supplements? If yes please list below:

Medication/Supplement Start Date Dose
2 5 0 0 H o s p i t a l D r i v e , B u i l d i n g 7 , M o u n t a i n V i e w , C A 9 4 0 4 0650-325-N O V A ( 6 6 8 2 ) n o v a i v f . c o m

Social History:

Are you currently in a relationship?
If yes, duration of relationship
years and months
Are you currently using a method to keep you from getting pregnant?
If yes, what method(s):
How many caffeinated beverages (coffee, soda, tea) do you drink per day?
On average how much water are you consuming daily?
Do you exercise regularly?
If yes, describe:
Any history of significant weight loss/gain in last 12 months?
Any history of eating disorders?
Do you smoke cigarettes or have you ever used tobacco products?
Do you drink alcohol?
Have you ever used illicit drugs?
Are you allergic to any foods?
If yes, describe:

Family History:

Have any of these illnesses occurred in your family:

Immunization History:

Chickenpox (Varicella):
dates()
MMR-Measles, Mumps, Rubella (German Measles):
dates()
Tetanus (Tdap):
dates()
Hepatitis B:
dates()
Polio:
dates()
Influenza:
dates()
2 5 0 0 H o s p i t a l D r i v e , B u i l d i n g 7 , M o u n t a i n V i e w , C A 9 4 0 4 0650-325-N O V A ( 6 6 8 2 ) n o v a i v f . c o m