New Patient Intake Full

1
How did you hear about us?* This field is required.
obgyn
urology
insurance
friend
online
2
Who referred you?* This field is required.
3
Where online did you hear about us?* This field is required.
4
Tell us about your goals in seeing Fora Fertility* This field is required.
Huge
Large
Normal
Small
Ok
Ok
5
How many kids would you like to add to your family or what would your ideal family look like?* This field is required.
6
Tell us something about yourself* This field is required.
Huge
Large
Normal
Small
Ok
Ok
7
Name* This field is required.
First Name
Middle Name
Last Name
8
Preferred name* This field is required.
9
What are your pronouns?* This field is required.
he/his
her/hers
they/them
10
What was your sex assigned at birth?* This field is required.
Male
Female
11
Is this the current gender you identify with?* This field is required.
YESNO
12
Please describe your current gender identify and any circumstances important for us to know such as reproductive surgery or hormonal transitioning* This field is required.
Huge
Large
Normal
Small
Ok
Ok
13
Date of Birth* This field is required.
Date
Month
Day
Year
14
Age* This field is required.
15
Social Security Number* This field is required.
16
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
17
Preferred Phone* This field is required.
Please enter a valid phone number.
18
Email* This field is required.
example@example.com
19
Occupation* This field is required.
20
Pharmacy* This field is required.
Pharmacy Name
Pharmacy Phone Number
21
Who currently takes care of your reproductive health?* This field is required.
Ob/Gyn
Urologist
PCP name and practice
22
Physicians Name?* This field is required.
23
Medical history chart* This field is required.Do you or have you ever had (check all that apply):
Anemia
Appendicitis
Bleeding disorder
Breast discharge
Cancer
Cardiac/heart issues
Chickenpox
Clotting disorder
Diabetes
Eating disorders
Endocrine disease
Endometriosis
GI/stomach/bowel disorder
Headaches
Hypertension
Joint disorder
Liver disease
Neurologic disorder
Parasitic infection
Pneumonia
Psychological
Pulmonary/lung disorder
Renal/kidney disease
STDs
Stroke/TIA
Thyroid disorder
Tuberculosis
Inability to smell
Other
None
24
Please Describe Other* This field is required.
Huge
Large
Normal
Small
Ok
Ok
25
What is your height & weight?* This field is required.
Height
Weight
26
Do you have allergies to meds?* This field is required.
YESNO
27
If yes, please list here:* This field is required.
Huge
Large
Normal
Small
Ok
Ok
28
Are you currently taking any prescription, over-the-counter medication, or herbal supplements on a regular basis? Please note below:
Medication/Herbs
Diagnosis
Dosage/Frequency
Duration
1
2
3
4
5
1
2
3
4
5
Medication/Herbs
Diagnosis
Dosage/Frequency
Duration
Medication/Herbs
Diagnosis
Dosage/Frequency
Duration
Medication/Herbs
Diagnosis
Dosage/Frequency
Duration
Medication/Herbs
Diagnosis
Dosage/Frequency
Duration
Medication/Herbs
Diagnosis
Dosage/Frequency
Duration
1 of 5
29
Within the last year, have you taken prescription medication for longer than 2 weeks? Please note below:
Medication/Herbs
Diagnosis
Dosage/Frequency
Duration
1
2
3
4
5
1
2
3
4
5
Medication/Herbs
Diagnosis
Dosage/Frequency
Duration
Medication/Herbs
Diagnosis
Dosage/Frequency
Duration
Medication/Herbs
Diagnosis
Dosage/Frequency
Duration
Medication/Herbs
Diagnosis
Dosage/Frequency
Duration
Medication/Herbs
Diagnosis
Dosage/Frequency
Duration
1 of 5
30
Please write down all surgeries you have undergone:
Year
Hospital
Procedure
Findings
Surgeon
1
2
3
4
1
2
3
4
Year
Hospital
Procedure
Findings
Surgeon
Year
Hospital
Procedure
Findings
Surgeon
Year
Hospital
Procedure
Findings
Surgeon
Year
Hospital
Procedure
Findings
Surgeon
1 of 4
31
Do you use or have you ever used (check all that apply):
Alcohol
Cigarettes/Tobacco
Illicit or recreational drugs (marijuana, cocaine, etc.) – If you would feel more comfortable not writing anything down, please discuss this directly with your physician.
Caffeine
Exercise
32
Alcohol: How many drinks per week?* This field is required.
33
Smoke:* This field is required.
How Long?
How many per day?
34
Illicit or recreational drugs:* This field is required.
Which ones?
Describe use
35
Caffeine: How many cups per day?* This field is required.
36
Exercise:* This field is required.
Time per day?
Days per week?
37
Family History Chart* This field is required.Please check all that apply
Yes/No
Which specific relative? (Include maternal or parental)
Diabetes
Yes
No
Cardiovascular
Yes
No
Cancer
Yes
No
Blood clot or bleeding disorder
Yes
No
Birth defects
Yes
No
Delayed Fertility
Yes
No
Miscarriages
Yes
No
Hormonal disorders
Yes
No
Thyroid Disease
Yes
No
Hereditary disease
Yes
No
Hypertension
Yes
No
Other
Yes
No
Diabetes
Cardiovascular
Cancer
Blood clot or bleeding disorder
Birth defects
Delayed Fertility
Miscarriages
Hormonal disorders
Thyroid Disease
Hereditary disease
Hypertension
Other
Yes/No
Yes
No
Which specific relative? (Include maternal or parental)
Yes/No
Yes
No
Which specific relative? (Include maternal or parental)
Yes/No
Yes
No
Which specific relative? (Include maternal or parental)
Yes/No
Yes
No
Which specific relative? (Include maternal or parental)
Yes/No
Yes
No
Which specific relative? (Include maternal or parental)
Yes/No
Yes
No
Which specific relative? (Include maternal or parental)
Yes/No
Yes
No
Which specific relative? (Include maternal or parental)
Yes/No
Yes
No
Which specific relative? (Include maternal or parental)
Yes/No
Yes
No
Which specific relative? (Include maternal or parental)
Yes/No
Yes
No
Which specific relative? (Include maternal or parental)
Yes/No
Yes
No
Which specific relative? (Include maternal or parental)
Yes/No
Yes
No
Which specific relative? (Include maternal or parental)
1 of 12
38
Have you been trying to conceive?* This field is required.
YESNO
39
How long?* This field is required.
40
Are you using any form of contraception at the current moment?* This field is required.
41
Do you have a uterus?* This field is required.
YESNO
42
What age did you start your period?* This field is required.
43
When was the first day of your last menstrual period (LMP)?* This field is required.
Date
Month
Day
Year
44
Are your periods regular?* This field is required.
YESNO
45
How many days between cycles?* This field is required.
46
Are you detecting ovulation?* This field is required.
YESNO
47
Tracking cycles?* This field is required.
YESNO
48
Painful?* This field is required.
No
Mild
Moderate
Severe
49
Have you been diagnosed with uterine fibroids or myomas?* This field is required.
YESNO
50
Have you been diagnosed with endometriosis?* This field is required.
YESNO
51
When was your last pap smear?* This field is required.
Date
Month
Day
Year
52
Was it normal?* This field is required.
YESNO
53
Have you ever had any abnormal paps?* This field is required.
YESNO
54
Have you had cryotherapy, LEEP, cone biopsy, or any surgery on your cervix?* This field is required.
YESNO
55
Any history Sexually Transmitted infections (HPV, herpes, gonorrhea, chlamydia, syphilis, HIV, etc.)?* This field is required.
YESNO
56
Sexually Transmitted infections: Describe* This field is required.
Huge
Large
Normal
Small
Ok
Ok
57
Do you have any difficulty (pain/libido/orgasm) with intercourse?* This field is required.
YESNO
58
Difficulty with intercourse: Describe* This field is required.
Huge
Large
Normal
Small
Ok
Ok
59
Have you had any procedures which may impact your reproduction?* This field is required.
YESNO
60
Procedures impact reproduction: Describe* This field is required.
Huge
Large
Normal
Small
Ok
Ok
61
Have you ever been pregnant or contributed to a pregnancy?* This field is required.
YESNO
62
Please fill in the chart below:* This field is required.
Ending Year
How long did it take to conceive?
Fertility therapy required to conceive?
Greater than or equal to 37 weeks?
Miscarriage? Induced abortion? Ectopic pregnancy?
Live birth?
With the current partner?
1st pregnancy
Yes
No
Yes
No
Miscarriage
Induced abortion
Ectopic pregnancy
Yes
No
Yes
No
2nd pregnancy
Yes
No
Yes
No
Miscarriage
Induced abortion
Ectopic pregnancy
Yes
No
Yes
No
3rd pregnancy
Yes
No
Yes
No
Miscarriage
Induced abortion
Ectopic pregnancy
Yes
No
Yes
No
1st pregnancy
2nd pregnancy
3rd pregnancy
Ending Year
How long did it take to conceive?
Fertility therapy required to conceive?
Yes
No
Greater than or equal to 37 weeks?
Yes
No
Miscarriage? Induced abortion? Ectopic pregnancy?
Miscarriage
Induced abortion
Ectopic pregnancy
Live birth?
Yes
No
With the current partner?
Yes
No
Ending Year
How long did it take to conceive?
Fertility therapy required to conceive?
Yes
No
Greater than or equal to 37 weeks?
Yes
No
Miscarriage? Induced abortion? Ectopic pregnancy?
Miscarriage
Induced abortion
Ectopic pregnancy
Live birth?
Yes
No
With the current partner?
Yes
No
Ending Year
How long did it take to conceive?
Fertility therapy required to conceive?
Yes
No
Greater than or equal to 37 weeks?
Yes
No
Miscarriage? Induced abortion? Ectopic pregnancy?
Miscarriage
Induced abortion
Ectopic pregnancy
Live birth?
Yes
No
With the current partner?
Yes
No
1 of 3
63
Do you have any other children? Adoption, surrogacy, or that your partner carried?* This field is required.
YESNO
64
Other children: Describe* This field is required.
Huge
Large
Normal
Small
Ok
Ok
65
Have you had any fertility evaluation or treatment in the past?* This field is required.
YESNO
66
Physician? blanks *
Diagnosis? blank *
67
Which of the following tests have you had performed (check all that apply and provide results if known):
Have you had this test?
Date
Results
AMH
Day 3 FSH / Estradiol
Hysterosalpingogram (HSG)
Laparoscopy
Hysteroscopy
Thyroid Tests
Rubella
Saline Ultrasound
Mammogram
Genetic Screening
Semen analysis
Other:
AMH
Day 3 FSH / Estradiol
Hysterosalpingogram (HSG)
Laparoscopy
Hysteroscopy
Thyroid Tests
Rubella
Saline Ultrasound
Mammogram
Genetic Screening
Semen analysis
Other:
Have you had this test?
Date
Results
Have you had this test?
Date
Results
Have you had this test?
Date
Results
Have you had this test?
Date
Results
Have you had this test?
Date
Results
Have you had this test?
Date
Results
Have you had this test?
Date
Results
Have you had this test?
Date
Results
Have you had this test?
Date
Results
Have you had this test?
Date
Results
Have you had this test?
Date
Results
Have you had this test?
Date
Results
1 of 12
68
Treatments you've had:
# of cycles
Max Dose
Comments
Clomid
Clomid + IUI
Letrozole / Femara
Letrozole + IUI
Injectable
Injectable + IUI
Clomid
Clomid + IUI
Letrozole / Femara
Letrozole + IUI
Injectable
Injectable + IUI
# of cycles
Max Dose
Comments
# of cycles
Max Dose
Comments
# of cycles
Max Dose
Comments
# of cycles
Max Dose
Comments
# of cycles
Max Dose
Comments
# of cycles
Max Dose
Comments
1 of 6
69
IVF cycles:
# of cycles
# of eggs/# of embryos
Comments/outcomes
IVF
IVF + genetic screening
Frozen Embryo Transfers
IVF
IVF + genetic screening
Frozen Embryo Transfers
# of cycles
# of eggs/# of embryos
Comments/outcomes
# of cycles
# of eggs/# of embryos
Comments/outcomes
# of cycles
# of eggs/# of embryos
Comments/outcomes
1 of 3
70
Do you have insurance?* This field is required.
YESNO (Self - Pay)
71
Primary Insurance - PATIENT (1 of 2)* This field is required.
Insurance Company Name
Subscriber ID Number
Subscribers Name
Sex
Group Number
Copay
Subscriber's Date of Birth
Relationship to Patient
72
Primary Insurance - PATIENT (2 of 2)
Insurance Phone Number
Claims Address
73
Do you have a partner?* This field is required.
YESNO
74
Please complete the following information as it best describes your partner. You do not need to repeat information pertaining to fertility testing and treatment unless your partner has previously had their own evaluation or undergone fertility treatment.
75
Name* This field is required.
First Name
Middle Name
Last Name
76
Preferred name* This field is required.
77
What are your pronouns?* This field is required.
he/his
her/hers
they/them
78
What was your sex assigned at birth?* This field is required.
Male
Female
79
Is this the current gender you identify with?* This field is required.
YESNO
80
Please describe your current gender identify and any circumstances important for us to know such as reproductive surgery or hormonal transitioning* This field is required.
Huge
Large
Normal
Small
Ok
Ok
81
Date of Birth* This field is required.
Date
Month
Day
Year
82
Age* This field is required.
83
Social Security Number* This field is required.
84
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
85
Preferred Phone* This field is required.
Please enter a valid phone number.
86
Email* This field is required.
example@example.com
87
Occupation* This field is required.
88
Pharmacy* This field is required.
Pharmacy Name
Pharmacy Phone Number
89
Who currently takes care of your reproductive health?* This field is required.
Ob/Gyn
Urologist
PCP name and practice
90
Physicians Name?* This field is required.
91
Medical history chart* This field is required.Do you or have you ever had (check all that apply):
Anemia
Appendicitis
Bleeding disorder
Breast discharge
Cancer
Cardiac/heart issues
Chickenpox
Clotting disorder
Diabetes
Eating disorders
Endocrine disease
Endometriosis
GI/stomach/bowel disorder
Headaches
Hypertension
Joint disorder
Liver disease
Neurologic disorder
Parasitic infection
Pneumonia
Psychological
Pulmonary/lung disorder
Renal/kidney disease
STDs
Stroke/TIA
Thyroid disorder
Tuberculosis
Inability to smell
Other
None
92
Please Describe Other* This field is required.
Huge
Large
Normal
Small
Ok
Ok
93
What is your height & weight?* This field is required.
Height
Weight
94
Do you have allergies to meds?* This field is required.
YESNO
95
If yes, please list here:* This field is required.
Huge
Large
Normal
Small
Ok
Ok
96
Within the last year, have you taken prescription medication for longer than 2 weeks? Please note below:
Medication/Herbs
Diagnosis
Dosage/Frequency
Duration
1
2
3
4
5
1
2
3
4
5
Medication/Herbs
Diagnosis
Dosage/Frequency
Duration
Medication/Herbs
Diagnosis
Dosage/Frequency
Duration
Medication/Herbs
Diagnosis
Dosage/Frequency
Duration
Medication/Herbs
Diagnosis
Dosage/Frequency
Duration
Medication/Herbs
Diagnosis
Dosage/Frequency
Duration
1 of 5
97
Please write down all surgeries you have undergone:
Year
Hospital
Procedure
Findings
Surgeon
1
2
3