Page 1 of 5 16 East 40 th St, 2 nd Fl, New York, NY 10016 Ph 212-679-2289 fax 212-679-2288 Fertility Evaluation Please complete the following for patient who will be egg provider and carrier. If partner is going to be the carrier the same form should be completed for partner. Name: Date of birth: Age: Partner s Name: Date of birth: Age: Primary care provider: OB-GYN provider: Last Menstrual Period: On active birth control/ type? Current medications: Allergies: Reaction: Obstetrical History: Have you ever been pregnant? Have you been pregnant with your current partner? Preg. # Year Time to conceive Type of fertility treatment? (If any) Weeks carried Outcome (e.g. Live, fetal heartbeat, miscarriage, D&C, genetic testing results) Type of delivery Complications Current partner? Gynecologic History: When was your last Pap smear? Result: Have you had a mammogram?
Page 2 of 5 Tubal ligation? Reason? Vaginal discharge? Is it associated with an odor, itching, or burning? Please include dates and treatment if you ever had: Mother who took DES: Pelvic infection: Chlamydia/gonorrhea: Herpes: Vaginitis: Endometriosis: Ovarian cysts: Genital warts: Abnormal Pap: List dates and nature of any pelvic surgery: Have you ever had a tubal ligation? If so, give details Birth Control: Have your ever used the following? Birth control pills, IUD, diaphragm, condoms, norplant, depo-provera, foam, sponge, other? Method Dates How long? Why did you stop? Complications Menstrual History: Date of last menses: Age at onset of your menstrual period: Average length between cycles (from day 1 of full flow to next next day 1):
Page 3 of 5 Any history of irregular menses, spotting, or missed menses? If yes, please explain (include dates): Amount of bleeding: Light Medium Heavy Have you taken medications to induce a period? Painful menses? Does the pain start with bleeding? Does the pain last longer than 48 hours? Please list any medications you take for cramps: Ovulation History: Do you experience: Premenstrual cramps? Clear discharge mid-cycle? Monthly cycles? Pain at midcycle? Have you ever used the following: Basal body temperature: months. Temperature shift: Day of shift: Ovulation predictor kit: # cycles: LH surge? Yes No Day of LH surge: Hormonal Assessment: Have you ever experienced any of the following: Weight gain/loss of 10+ pounds Discharge or milk from nipples Change in vision Unusual sensitivity to hot or cold Excessive change in hair growth/loss Acne or oily skin Thyroid disease, diabetes, or other hormonal abnormalities Medical History: Please list any medical/psychiatric conditions that you have or had in the past and any medications used in treatment. List dates.
Page 4 of 5 Surgical/Hospitalization History: Please list any surgeries or hospitalizations you have had. List dates. Family History: Please list any family history of infertility, genetic problems, thyroid disease, diabetes, cancer, or any other major medical problems. Social History: Occupation: Travel for work: Frequency: Caffeine intake: Do you smoke cigarettes? Packs per day Alcohol consumption: drinks/week Type: How frequently do you have intercourse? per week/month Medications: Prescription Over the counter Recreational (marijuana, hallucinogens, crack/cocaine) List the form and frequency of any regular exercise Have you ever been told you have or suspected you have an eating disorder? Previous Infertility Treatment: Please describe results and include dates. Name of physician/practice: Have you had any hormonal blood tests? Have you ever had an endometrial biopsy? Have you ever had an HSG (x-ray of your tubes and uterus)?
Page 5 of 5 Have you ever had a saline ultrasound (fluid ultrasound)? Have you ever had a laparoscopy or laparotomy? Have you ever taken fertility medications? Have your ever had intrauterine inseminations? Have you had IVF before? Details of past IVF treatments Clinic Date Type of cycle (fresh or frozen) Stimulation Protocol # eggs #embryos Result Frozen embryos remaining Reason for leaving clinic Have you ever used donor eggs, donor sperm, or a gestational carrier? Comments: Patient Signature: Date: Please remember to have partner print out and complete this form if they will be the carrier The above information was reviewed with patient on: Date Physician Name: Signature