Name Date. 5. Your attending physician/ Reproductive Endocrinologist is: If so, what was it? If so, is there any male factors diagnosed?

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1 Female Fertility Intake Form Name Date 1. What is the purpose of your visit today? Preparation for pregnancy without medical intervention Adjunct to assisted reproductive technology 2. Estimated date of procedure for IVF IUI 3. Is this your first attempt? If not, how many? IVF IUI 5. Your attending physician/ Reproductive Endocrinologist is: 6. Have you had an infertility diagnosis? If so, what was it? 7. Has your partner had his reproductive status evaluated by a physician? If so, is there any male factors diagnosed? Is your partner supportive of your wish to become pregnant? Y/N 8. How long have you been trying to conceive? 9. Have you ever gotten pregnant naturally? How many times? Live births Abortions Performed D&C Miscarriages How far along into the pregnancy? Past Fertility Treatments (including cancelled cycles): On the lines below please list: Date, Natural, IUI, Medication used, # of mature eggs, # of follicles, Pregnancy, Miscarriage, lvf, other.

2 Future ART Plans Will you be using Donor Eggs? Y/N Will you be using donor sperm? Y/N 10. Have you ever been diagnosed with any of the following gynecological diseases? venereal disease yeast infection pelvic inflammatory disease uterine fibroids endometriosis polycystic ovary chlamydial infection pelvic adhesions uterine abnormalities tubal blockage pelvic abnormalities Have you ever been diagnosed with uterine fibroids or polyps? Yes No Have you ever been diagnosed with endometriosis? Yes No Have you ever been diagnosed as perimenopausal? Do you experience hot flashes at any time during your menstrual cycle? Have you been exposed to any known environmental toxins or hormones? Yes No Have you ever had an IUD? Yes No Hormonal or Copper? When How long? Have you ever taken DepoProvera? Yes No When How long? Have you taken any medications for gynecological conditions other than

3 contraceptives? Have your fallopian tubes been evaluated medically (ie HSPG)? Yes No What were the results? Have you had any gynecological related operations? Yes No Have you had any hormone laboratory tests performed? Yes No What were the results? Do you douche regularly? Yes No Do you use vaginal lubricants? Yes No If so, which brand(s) 11. Have you ever been diagnosed with hypothyroidism? 12. Have you been diagnosed with having abnormal prolactin level? 13. Have you ever used contraceptives? For how long and which kind(s)? 14. Date of last menstrual period 15. Do you spot during midcycle? 16. Premenstrual symptoms: headache/migraine diarrhea/ loose stools fatigue acne night sweats irritability/mood swings bloating nausea sugar cravings breast tenderness abdominal cramp low back pain yeast herpes outbreaks itching 17. Menstruation How many days between menstrual cycles typically ( day1 to day1)? In the past 12 months, the cycle has become: Longer Shorter The same How many days do you normally bleed? In the last few cycles, the amount of bleeding has become More Less The same Describe the color, consistency of the bleeding:

4 Bleeding begins brown Clotting Large Clotting Small Bearing down sensation Red Brown/ Black Thin red, like water Thick with mucous Stop and start flow Spotting before/after Prolonged Heavy bleeding Scanty bleeding Piercing pain Distending pain Low back pain Pain relieved by heating pad Pain relieved with onset of the flow 18. Ovulation Do you ovulate on your own? On what day of the cycle? Has this been confirmed with monitor or BBT chart? Do you notice stretchy egg white quality cervical mucous around ovulation? Do you have pain during ovulation? Do you breast get tender during ovulation? 19. Vaginal Discharge: Do you have profuse vaginal discharge other than mid cycle cervical mucous? Do you have chronic vaginal discharge? 20. Libido: (low) (high) 21. Life Style: Your profession: Stress level ( 1 10) Exercise routine: none moderate excessive Energy level (0 10) Current weight Target weight

5 Do you drink water or other beverages from a plastic bottle? Y/N Do you microwave food in plastic containers? Y/N Emotional status: anxiety panic attacks depression nervousness worry anger grief fear/phobia obsession insomnia Stress management: acupuncture massage meditation yoga breathing exercise spiritual practice recreation