BACKGROUND INFORMATION FOR INITIAL CONSULTATION

BACKGROUND INFORMATION FOR INITIAL CONSULTATION + CONFIDENTIAL + Business Phone ti: Age: Social Security #: )ductive Medicine? Have you ever had an IVF, GIFT or ZIFT procedure done? If so, when and where? Briefly, what was the outcome? no Please state the n you wish to have a consultation: ditadi@jl in case- T o WIFE'S OB/Gpi _HISTORY ipn en: jell& Do you have regular menstrual periods? 5 -I 'IP aut(evt 914 cyl so cortird If so, how often do you menstruate? How many days does menstrual flay Is flow light, moderate or heavy? Do you experience pain or cramping between or during menstrual periods? • a:Mt/065 Have you ever be ldiagnosed with endometriosis? Have you ever been told that your uterus is abnormally shaped (T shaped or "bicornuate")? 00 Have you ever been told that you are a "DES daughter", i.e., did your mother take DES during her pregnancy? I o How long have you been trying to become pregnant? Ni ft Have you ever been pregnant in the past? 11O Dates of pregnancy or pregnancies: Duration of pregnancy or pregnancies: How many of these pregnancies resulted in: live birth(s) miscarriage(s) Patient's: Height:al it Weight: l 2;3 voluntary abortion(s) ectopic(s) Name of current OB/GYN: EFTA00553609