Simple Steps Fertility Egg Donor / Surrogate Questionnaire 12Gynecologic History3Previous Egg Donation4Medical History5Current Medications6Previous Surgeries7Obstetrical History8Family History9Social History Patient Name(Required) Date(Required) MM slash DD slash YYYY Please complete this quastionaire as accurately as possible, and please feel free to take a copy for your records. If you have any questions regarding this form your physician will assist you during the consultation. If you need any help with translation, please ask and a stuff member will help you. Reason for Visit:Reason for Visit:(Required) Egg Donation Surrogacy Who is your Ob/Gyn?Name(Required) Phone(Required) Address(Required) When was then last you visited your Ob/Gyn?(Required) Who is your Primary Care Physician?Name(Required) Phone(Required) When was then last you visited your Primary Care Physician?(Required) How did you hear about us?(Required) What is your Ancestry / Ethnic Background?(Required) Have you served as an egg donor, sperm or gestational carrier/surrogate before?(Required) Yes No If so, how many times? When was the first day of your last period?(Required) Are your periods regular or irregular?(Required) How often do you get your periods?(Required) How many days of bleeding do you experience?(Required) Have there been recent changes in your menstrual patterns?(Required) Do you have pain with menstruation?(Required) Do you experience pain with sexual intercourse?(Required) Do you experience pain with ovulation?(Required) Date of your last Pap smear?(Required) Did you ever have an abnormal Pap smear?(Required) When?(Required) Have you ever had a sexually transmitted disease?(Required) If so, when?(Required) Have you ever had Pelvic Inflammatory Disease (PID)?(Required) If so, when?(Required) Have you ever used Oral Contraceptive Pills?(Required) Yes No What type/brand?(Required) Did you have any side effects/reactions?(Required) How many years?(Required) When did you last use the pils?(Required) Previous Egg Donation Date of Procedure # of Eggs Retrieved Outcome/Complications Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Please state if you have or have had any of the following conditions: Medical History Medical Disease History Comments Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Please list any medications that you are currently taking. Current Medications Medication Dose Frequency Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Are you allergic to any medication?(Required) Yes No Current Medications Medication Reaction to the Medication Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Previous Surgeries Procedure Date Outcome/Complications Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Have you ever experienced any complications due to anasthesia?(Required) Have you ever been pregnant before?(Required) Yes No Date(Required) MM slash DD slash YYYY Current/Prior Partner(Required) Live Birth(Required) Yes No Miscarriage/Abortion/Ectopic(Required) Weeks(Required) Fetal Heart(Required) Yes No D&C(Required) Yes No Obstetrical History Natural or C-Section Sex Wt Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Please state if any of your family members have any of the following conditions: Family History Family History History Comments Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Do you use tobacco?(Required) Yes No #Packs/day Have you ever used tobacco before?(Required) Yes No Years Do you use alcohol?(Required) Yes No #Drinks/wk Do you use recreational/street drugs?(Required) Yes No If so, what type and how often? Do you use caffeine?(Required) Yes No What Type? #Drinks/day Do you exercise regularly?(Required) Yes No What type of exersize do you do? What is your occupation?(Required) On a scale of 1-10 (10 being the worst), estimate the level of stress you feel due to your job.(Required) Are you married?(Required) Yes No Are you currently sexually active?(Required) Yes No How many sexual partners have you had in the past years? Do you have any tattos?(Required) Yes No Please list the location on your body and the year you were tattooedDo you have any piercings?(Required) Yes No Please list the location on your body and the year you were piercedAre there any other aspects of your medical, surgical, family and/or social history that you thinks your doctor should know?(Required)CommentsPlease upload a picture of you and your family(Required) Drop files here or Select files Max. file size: 2 GB, Max. files: 10. Thank you for taking the time to complete our questionnaire. Your doctor will review this questionnaire with you. As a part of your initial evaluation your doctor may perform a focused physical exam and a pelvic ultrasound that is directed to assess reproductive health. This exam is in no way a replacement for a comprehensive routine physical exam that you should receive annually or more frequently as determined by your age and medical history. Δ
