Center for Reproductive Health and Gynecology Intake Form

First Name *

Last Name *

Phone *

Email *

Address *

City *

State *

Postal code *

Country *

How Did You Hear About Us? *

Date of birth *

Ethnicity *

Age *

Height *

Weight *

Reasons for Visit *

If You Answered Other for Reason for Visit, Explain Below

Fertility History

How Long Have You Been with Your Current Partner?

How Long Have You Been Trying to Conceive?

Have You Had Any Prior Treatments?

Yes

Have you ever had any infertility diagnostic testing?

Yes

Has your partner ever had any testing completed?

Yes

Have you ever been pregnant?

Yes

How many live births have you had?

Have you had any miscarriages?

Yes

How many miscarriages have you had, and when?

Have you ever had any elective abortions?

Yes

How many elective abortions have you had, and when?

Have you ever had an ectopic pregnancy?

Yes

How many ectopic pregnancies have you had, and when?

Please select any of the following conditions that you have been diagnosed with

What other conditions have you been diagnosed with?

First Day of Your Last Menstrual Cycle

Date of expected next menses

Menses (Period)

Regular

Irregular

How often do you get your menses (Period)

Every 28 Days

Every 30 Days

Other

How often do you get your menses if not 28 or 30 days?

How many days does your menses last, since you selected "Other?"

Have you ever taken birth control pills?

Yes

When was the last time you took birth control pills?

Do you have any bleeding after intercourse (sex)?

Yes

Do you have any spotting or bleeding mid cycle?

Yes

How old were you when you got you first period?

How old were you when you first had intercourse?

How many sexual partners have you had?

Do you have any history of STDs?

Yes

If yes, what STDs?

Gonorrhea

Chlamydia

Herpes

Other

What other STD were you diagnosed with?

Have you ever had an intra uterine device (IUD)?

Yes

Have you ever had pelvic inflammatory disease?

Yes

When was your last Pap Smear?

Were the results of your last pap smear normal?

Yes

Have you ever had abnormal Pap smear results?

Yes

When did you last have abnormal Pap smear results?

Have you ever had a mammogram?

Yes

Were the mammogram results normal?

Yes

Have you ever had abnormal mammogram results?

Yes

When was the last abnormal mammogram result?

If you have a family history of any of the following conditions, please list their relation to you

Breast Cancer
Ovarian Cancer
Uterine Cancer
Infertility
Genetic Abnormalities
If yes, what abnormality?
Early Menopause (Under 40)
Recurrent Pregnancy Loss in the Family (More than 2-3 miscarriages)

Mothers Current Age

Mother's Age of Menopause

Do you smoke?

Yes

If yes, how many cigarettes do you smoke per day?

Do you do any drugs?

Yes

If yes, what drugs and how often?

Do you drink alcohol?

Yes

If yes, how much alcohol and how often?

Do you have any allergies?

Yes

If yes, what are you allergic to?

Are you allergic to any medications?

Yes

If yes, what medications are you allergic to, and what is your reaction?

Please list all medications you are currently taking along with the strength and dosage

Please upload any documents that would pertain to your infertility testing

Please fill out the following intake information to get started! At the end of each page, just click the forward arrow, then make sure you hit submit at the end!