Patient Packet Form

Insurance Information

Incompletion of insurance information may delay care- If applicable.
Please complete insurance information regardless of fertility benefits, as some testing may be covered.
Have you read the above statement?*

YesNo
Policyholder Name

First NameLast Name
Insurance company (if no insurance please enter NA if not applicable)*
Examples: United HealthCare, Cigna, BlueCross/BlueShield)
Group #
Member ID (if no insurance please enter NA if not applicable)*
Type of Insurance Plan

HMOPPOMedicareMedicaidOther
Claim mailing address
Refer to back of card for information
Insurance Precertification Phone Number (located back of card, NA if not applicable)*
Insurance Customer Service Phone Number
Please enter a valid phone number.
Do you have secondary insurance?

YesNo

Secondary Insurance Information
Policyholder Name

First NameLast Name
Group #
Member ID
Type of Insurance Plan

HMOPPOMedicareMedicaidOther
Claim phone number (located on the back of your card)
Please enter a valid phone number.
Claim mailing address

Pharmacy Information
Pharmacy Name
Pharmacy Number
Pharmacy Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have a mail order pharmacy?

Yes (another page will ask information)No

Mail Order Pharmacy
Mail Order Pharmacy Name
Mail Order Pharmacy Phone Number
Please enter a valid phone number.
Mail Order Pharmacy Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

	Age (years old)
Breast Development
Pubic Hair
Underarm Hair

PREGNANCY HISTORY

If applicable

Pregnancy Summary (if applicable)

	Date	Time attempting pregnancy	Fertility Treatment	Outcome
1
2
3
4
5
6

Additional Information:

Full Term Deliveries

	Number of
Full Term Deliveries
How many were live births?
How many were stillborn?
Current Partner yes/no

Premature Deliveries

	Number of
Premature Deliveries (less than 20 weeks)
How many were live births?
How many were stillborn?
Current Partner yes/no

Please provide additional information:

	Year/Treatment
Chlamydia
Gonorrhea
Herpes
Genital warts/HPV
Syphillis
HIV/AIDS
Hepatitis
Other

	Please explain
Do you smoke cigarettes?
If yes, how many years?
If you quit, how long ago?
Are you exposed to second-hand smoke?
If you want to quit, are you interested in resources?

	If needed, please explain
Beer (# per week)
Wine (# per week)
Liquor (# per week)

Spouse/Partner Insurance/Pharmacy Information

If applicable
Is the pharmacy information the same as primary patient?

Yes - please leave page blankNo - please fill out below
Pharmacy Name
Pharmacy Number
Please enter a valid phone number.
Pharmacy Address
Street Address Line 2
City
State / Province
Postal / Zip Code

Insurance Information

Only fill if different from primary patient
Insurance Company Name
Policy Holder Name
ID Number
Group #
Type of Insurance Plan

HMOPPOMedicareMedicaidOther
Do you have a secondary insurance?

Yes (fill out below)No (skip below questions)
Policy holder's name
ID number
Group #
Claim mailing address

Closing thoughts/anything we may have missed?
Thank you for trusting us with your care.

Once you click submit, a member of our team will contact you within 2 business days.
Should be Empty:

	Yes	No	Number of Cycles
Clomiphene citrate/Clomid
Letrozole
FSH injectable med
hCG injectable med
Intrauterine insemination
IVF
Other

	Yes	No	Normal	Abnormal	Results
Urinary ovulation predictor kits
TSH
FSH blood test
AMH level
Semen analysis
Hysterosalpingogram
Pelvic ultrasound
Sonohysterography
Hysteroscopy

	Last Date/Range	Complications (Y/N)	Explain if needed
Condoms
Diaphragm
Birth Control Pills
Injectable contraception (Depo-Provera, Lunelle, etc)
Skin Patch
IUD
Foam or Jelly
Tubal Sterilization (tubes tied) - date in "explain" column
Tubes Untied - date in "explain" column
Implant (Nexplanon)
Natural Family Planning
Withdraw
Other

	Yes	No
Heart Disease
Thyroid Problems
Kidney Disease
Diabetes
Asthma
Blood clots (deep vein thrombosis/pulmonary embolus)
Exposure to blood products
Hepatitis
Cancer (if yes, please indicate type & treatment)
Arthritis
Lupus erythematosus
Stroke
High blood pressure
Lung problems
Endometriosis
Genetic disease
Depression
Psychiatric illness
Gallstones
Neurologic conditions
Uterine Fibroids
Ovarian cysts
Abnormal uterine bleeding

	Medication Name	Strength/dose	Frequency	Reason for taking
1.
2.
3.
4.
5.
6.

Insurance Information

Secondary Insurance Information

Pharmacy Information

Mail Order Pharmacy

Medical Information: Completion Required for Appointment

PREGNANCY HISTORY

Pap Smear & Mammogram History

Sexual History

History of Sexually Transmitted Infections & Pelvic Infections

Trauma Informed Care Assessment

Prior Fertility Evaluation

Contraceptive History

Allergies to Medications

Allergies to Non-Medications

Patient Medical History

Medication Review

Immunization History

Surgical History

Family History (include relationship to you)

Social History

Review of Systems

Partner/Spouse Information

Spouse/Partner Insurance/Pharmacy Information

Insurance Information

Sexual/Medical History

Spouse/Partner Medical History

Spouse/Partner Surgical History

Medications/Medical History

Review of Systems

Thank you for trusting us with your care.

	Relationship to you (mother, brother....)	Unsure if family history present
Diabetes
Thyrold Problems
Heart disease
Blood Clots
Obesity
Psychiatric Condition
Infertility
Menopause before 40
Cystic Fibrosis
Cancer (Type)
Neurologic (brain/spine)
High blood pressure
Glaucoma
Gallstones
Hepatitis
Tuberculosis
Endometriosis
Genetic Disease
Irritable Bowel Syndrome

	Yes	No	If needed, please explain
Recent weight changes
Anorexia/Bulimia
Lack of energy
Fever/Chills
Other

	Yes	No	If needed, please explain
Dizziness
Headaches
Loss of sense of smell
Ringing ears
Chronic nasal congestion
Blurred vision
Hearing loss/deafness
Other

	Yes	No	If needed, please explain
Hair loss
Thyroid gland problems
Rapid Weight Change
Excessive hunger/thirst
Temperature intolerance (hot flashes or feeling cold)
Hormonal Therapy
Other

	Yes	No	If needed, please explain
Discharge (clear, bloody, or milky)
Lumps
Pain
Cancer
Abnormal mammogram
Reduction
Augmentation/Breast Implants (saline or silicone)
Other

	Yes	No	If needed, please explain
Weakness
Loss of balance
Seizures
Headaches
Migraine headaches
Numbness
Memory loss
Other

	Yes	No	If needed, please explain
Nausea/Vomiting
Ulcers
Blood in your stools
Constipation
Diarrhea
Change in bowel habits
Colitis (ulcerative or Crohn's)
Other

	Yes	No	If needed, please explain
Bladder infections
Kidney infections
Vaginal infections
Frequent urination
Leaking urine
Blood in urine
Herpes
Other

	Yes	No	If needed, please explain
Unexplained rash/inflammation
ACNE
Skin cancer
Burn injury
Moles changing in appearance
EXCESS hair growth
Other

	Yes	No	If needed, please explain
Blood clotting disorder/blood clot
Sickle Cell Anemia
Easy Bruising
Thrombophlebitis
Swollen glands/lymph nodes
Excess hair growth
Blood transfusion (date and reasons)
Other

	Year	Type of Surgery	Reason	Complications
Surgery
Surgery
Surgery
Surgery

	Yes	No	How many (if applicable)?
Caffeinated Beverages (per day)
Marijuana
Cocaine

	Yes	No	If needed, please explain
Shortness of breath
Bronchitis
Bloody Cough
Other

	Yes	No	If needed, please explain
Unusual muscle weakness
Decreased energy/stamina
Other

	Yes	No	If needed, please explain
Palpitations/Skipped beats
Chest pain
Heart Attack
Murmurs
Rheumatic fever
Other

	Yes	No
Do you have (or have you had) erectile difficulty? (If applicable)
Do you have (or have you had) ejaculatory difficulty? (If applicable)
Do you (or have you had) a loss/change in libido (sex drive)?

	Yes	No	If needed, please explain
Heart Disease
Heart Murmur
Hypertension
Diabetes
Hepatitis
Cancer (if yes, please explain indicate type/treatment
Multiple sclerosis
Epilepsy
Asthma or lung/pulmonary disorder

	Yes	No	If needed, please explain
Orchidopexy (surgical repair of undescended testicle)
Orchiectomy (surgical removal of testicle) if yes, indicate diagnosis
Bladder neck surgery
Hernia repair
Pelvic surgery
Scrotal surgery
Retroperitoneal surgery (abdominal organs)
Transurethral
Other

	Yes	No	Treatment	Date
Gonorrhea
Chamydia
Syphilis
Herpes
Mumps
Viral
Prostatitis
Urethritis
Cystitis (bladder infections)
Pyelonephritis (kidney infection)
Epididymitis/orchitis (testicle infection)
Other

	Yes	No	Additional Information
Alcohol
Marijuana
Tobacco
Anabolic steroids
Have you now or have you ever used testosterone (gel, injection, patch, pills)
Are you currently using, or have you ever used, complementary therapies to enhance fertility potential? (i.e. acupuncture, Chinese medicine, herbal remedies)

	Yes	No	Please explain
Recent weight changes
Anorexia/Bulimia
Do you use a hot tub?
Lack of energy
Fever/Chills
Other

	Yes	If yes, please provide additional information
Weakness/loss of balance
Seizures/Epilepsy
Headaches
Migraine headaches
Numbness
Memory Loss
Other