EFTA01904191

BACKGROUND INFORMATION FOR INITIAL CONSULTATION + CONFIDENTIAL + Wife's Name: Birth Date: Address: Age: Social Security #: Home Phone #: Business Phone #: Husband's Name: Birth Date: Business Phone #: Age: Social Security #: How were you referred to CUMC's Center for Reproductive Medicine? Have you ever had an IVF, GIFT or ZIFT procedure done? If so, when and where? Briefly, what was the outcome? Please state the reason you wish to have a consultation: WIFE'S OB/GYN HISTORY Do you have regular menstrual periods? If so, how often do you menstruate? How many days does menstrual flow ("bleeding") last? EFTA_R1_00335788 EFTA01904191 Is flow light, moderate or heavy? Do you experience pain or cramping between or during menstrual periods? Have you ever been diagnosed with endometriosis? Have you ever been told that your uterus is abnormally shaped shaped or sbicornuate)? Have you ever been told that you are a 'DES daughter, i.e., did your mother take DES during her pregnancy? How long have you been trying to become pregnant? Have you ever been pregnant in the past? Dates of pregnancy or pregnancies: Duration of pregnancy or pregnancies: How many of these pregnancies resulted in: live birth(s) miscarriage(s) voluntary abortion(s) ectopic(s) Patient's: Height: Weight: Name of current OB/GYN: PROCEDURES Have you ever had a hysterosalpingogram (HSG) performed? If yes, date of procedure: Films should be obtained for appointment. EFTA_R1_00335789 EFTA01904192 What were the findings of the HSG (briefly)? Have you ever had a hysteroscopy or laparoscopy? If so, when? Briefly, what were the findings/results of the above operations? Have you had any other surgery performed in the pelvic or abdominal region? What surgery, and when was it performed? Have you ever had an endometrial biopsy performed? BLOOD TESTS Have you ever had the following hormones drawn on day 3 of your menstrual period? FSH (follicle stimulating hormone); LH (luteinizing hormone); and E2 (estradiol)? If so, list the results? FSH: LH: E2: AMH: Note: The hormones mentioned above must be drawn in our lab on the third day of your menstrual period and reviewed by our lab and Dr. Rosenwaks prior to setting up an appointment for initial consultation. Please contact the office at (646) 962-3743 for instructions. Do you have any history of major medical problems (other than those related to infertility)? If so, please describe: TESTS - BOTH PARTNERS Have you ever had a post-coital test? Briefly, what were the findings? Have you ever had an Antisperm Antibody test? Briefly, what were the findings? EFTA_R1_00335790 EFTA01904193 HUSBAND'S REPRODUCTIVE/UROLOGICAL HISTORY Was a semen analysis performed? Yes No Please provide the results: Volume: Density (count): Motility (movement): Morphology (shape): cro Normal: Have you ever been diagnosed with a varicocele? If so, did you have the varicocele repaired surgically? Have you ever been on antibiotics for an infection such as chlamydia or mycoplasma? Do you have any history of major medical problems (other than fertility-related)? If so, please describe: Please return this completed questions to: Zev Rosenwaks, M.D. CRMI Attn: Ms. Wally Padillo, M.A. 1305 York Avenue 6th floor New York, N.Y. 10021 It may also be faxed to us at: 646-962-0391, Attn: Wally Please do not mail any medical records until you have an actual appointment date. Please call after submitting this form to ensure that we have received it. Thank you for your interest in the programs offered through The Center for Reproductive Medicine at Cornell University. EFTA_R1_00335791 EFTA01904194