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May we contact you via email?
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Physician’s Name
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May we contact your doctor?
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How did you hear about us?
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Others, please specify
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May we thank your referral source?
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Health History
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Health History - Please select all that apply
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Others, please specify
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Current Medications
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Significant Surgeries and Dates
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General Intake
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Female Fertility Intake
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Male Fertility Intake
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Prenatal Intake
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Male Fertility History
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Semen Analysis Results and date
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Other male fertility history
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Fertility History
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How long have you been trying to conceive?
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Did you have a diagnosis related to fertility?
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If you are undergoing fertility treatment, what type of cycle?
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Tentative date of cycle/procedure
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Other details about your fertility cycle if applicable
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Reproductive Endocrinologist’s name
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May we contact your doctor?
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Previous Cycles
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1. Previous fertility treatments/cycles with results
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Date
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2. Previous fertility treatments/cycles with results
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Date
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3. Previous fertility treatments/cycles with results
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Date
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4. Previous fertility treatments/cycles with results
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Date
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Fertility Related Surgery
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Fertility Related Surgeries with Dates
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Pregnancy History
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How many pregnancies have you had?
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How many live births have you had?
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How many miscarriages have you had?
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How many abortions have you had?
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Anything else you would like us to know or address?
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Thank you for sharing this information! We look forward to working with you!
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Fertility History
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How long have you been trying to conceive?
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Did you have a diagnosis related to fertility?
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What type of cycle are you doing?
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Tentative date of cycle/procedure
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Other cycle specific information, if applicable:
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Reproductive Endocrinologist’s name
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OB/GYN’s name
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FSH results and date
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AMH Results and Date
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Additional test results and date
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Additional test results and date
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Previous Fertility Treatments
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1. Previous fertility treatments/cycles with results
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Date
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2. Previous fertility treatments/cycles with results
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Date
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3. Previous fertility treatments/cycles with results
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Date
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4. Previous fertility treatments/cycles with results
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Date
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5. Previous fertility treatments/cycles with results
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Date
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Fertility Related Surgeries
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1. Fertility Related Surgeries with Dates
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Menstrual History
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Date of last period
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On average, how many days between your periods?
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Do you ovulate on your own?
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If yes, what cycle day do you ovulate?
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Are you tracking your cycles?
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If yes, what are you using to track your cycle?
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Pregnancy History
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How many pregnancies have you had?
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How many live births have you had?
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How many miscarriages have you had?
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How many abortions have you had?
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Male Fertility History
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Semen Analysis Results and date
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Other male fertility history
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Anything else you would like us to know or address?
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Thank you for sharing this information! We look forward to working with you!
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Main Complaint
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What is the main reason for your appointment today?
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When did this problem begin?
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Have you received a diagnosis for this issue?
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Cause of issue, if known
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What makes it worse?
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What makes it better?
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Pain level, if applicable
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Secondary Complaint (If applicable)
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Secondary reason for your appointment today
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When did this problem begin?
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Have you received a diagnosis for this issue?
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Cause of issue, if known
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What makes it worse?
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What makes it better?
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Pain level, if applicable
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Is there anything else you would like us to know?
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Thank you for sharing this information! We look forward to working with you!
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Main Complaint
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What is the main reason for your appointment today?
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When did this problem begin?
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Have you received a diagnosis for this issue?
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Cause of issue, if known
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What makes it worse?
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What makes it better?
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Pain level, if applicable
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Secondary Complaint (if applicable)
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Secondary reason for your appointment today
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When did this problem begin?
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Have you received a diagnosis for this issue?
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Cause of issue, is known
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What makes it worse?
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What makes it better?
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Pain level, if applicable
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Current Pregnancy
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How far along are you currently?
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When is your due date?
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Any complications during this pregnancy?
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History of infertility/fertility treatments?
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Any spotting during this pregnancy?
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Any other pregnancy symptoms not listed?
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Pregnancy History
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How many pregnancies have you had?
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How many live births have you had?
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How many miscarriages have you had?
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How many abortions have you had?
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Any complications in previous pregnancies?
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History of premature birth? How many weeks?
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Any other labor/delivery complications?
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Major symptoms during prior pregnancies?
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Is there anything else you would like us to know?
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Thank you for sharing this information! We look forward to working with you!
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