Marinfertilitycenter.com

Name: ______________________________
Date of visit: _____/_____/_____
Age: ______ Height: ______
New Patient History
Please note: All information is confidential and will only be used for the purpose
of ensuring you the best treatment possible. Please answer all areas.
Why have you come to the office today?


Who referred you to our practice? Self Friend Physician (List name) ___________________
Who is your usual Ob/Gyn? __________________________ Location: _________________________________
Past Medical History ( if you have or have ever had)
Other medical problems(list):__________________________________________ Please expand on any problems you identified above:________________________________________________________ ___________________________________________________________________________________________________ Surgeries/Operations (any procedure, including D&C’s)
Type/Reason Date
Location
Physician
Other Illnesses/
Current Medications
Allergies/Reactions
(Include any hormones, vitamins, herbs, over
Hospitalizations
the counter and nonprescription medications)
(list any drug or food allergy)
Type/Reason Year
happens to you:
Gynecologic History
First day of last menstrual period: / /
Do you have regular monthly periods? Yes No
Do you feel period coming before it starts? Yes No Have you ever had an abnormal Pap test? Yes No
Which of the following do you experience before a period:
Breast tenderness  Mood changes Special food cravings
Usual number of days from start of
Have you ever had a procedure on your cervix due to an abnormal pap test? (LEEP / Cryo / Cone) Yes No Year: Any recent changes? Yes No Pain? Yes No When was your last Pap test? Describe: What was the Pap result? Normal Abnormal Year of last: ________ Result: Normal Abnormal Do you have problems with pelvic pain? Yes No Present method of birth control: (circle) None
Do you have pain with intercourse? Yes No Sexual partner(s) is/are: Men Women Both Female Sterilization (Tubal Ligation) Male Have you ever had any of the following infections? (circle) Weight at age 20: _________ Current Weight: _________ Have you ever used Birth Control Pills? Yes No Age when started birth control: ____ Age when last stopped: ____ Number of times: ______ Year(s): _____________
Hirsutism (excessive hair growth) & Acne
Do you feel that you have problems with excessive hair growth? Yes No
If yes, circle all areas of concern:
Face Chest/Breasts Back Stomach Arms Legs Thighs Age that hair growth became noticeably worse? _______ Does this continue to worsen? Yes No Prior Treatments: Waxing / Shaving / Plucking / Creams / Laser / Spironolactone (Aldactone) Treated how often? _____________________ Do you have problems with excessive acne? Yes No At what age did acne problems begin?
Obstetrical History
Immunizations
Type Date
Obstetrical History: Please list all pregnancies in order
Outcome (Yes/No)
Delivery:
Length of time
Required fertility
Complications
Live born
Miscarriage
Abortion
Vag / C-section
To conceive
Treatment?
partner?
Social History:
Currently Use:
Status: Married / Single Partner / No Partner Have you ever smoked >100 cigarettes? Yes No Length of time with current partner (years): ______
Family History (Parents, Grandparents, Siblings, Aunts/Uncles)
List affected relative(s) and age at onset
List miscarriages for both your family’s side and your partner’s
Fertility History (May STOP here if not being seen for fertility reasons)
Note: In order to help us more efficiently treat you, please obtain copies of your past fertility treatments,
operative reports, IVF cycle, ultrasound reports, labs, and hard copies (films or on disk) of any
How long have you been actively trying to conceive? ___ yrs ___ mo. Do you use lubricants? Yes No Type: _______ Hysterosalpingogram (HSG) (Xray test of your tubes) that you have had done. It is important that we review
the HSG films that were previously done. Please bring these records to your appointment with you. Number of times of intercourse per week? ______ How long have you been off any birth control? _____ yrs ____ mo. Frequency of intercourse near ovulation: _________ Prior Fertility Evaluation/Labs/Treatment
Were they able to detect if your tubes were open? Yes No Do you consistently ovulate? Checked by: Temperature / Urine Ovulation Testing / Ultrasound / Blood
Prior fertility treatments:
Please list dates, dosage, number of cycles:
Ovulation Induction with injectable fertility medications (Menopur, Bravelle, Repronex, Gonal-F, Follistim) Male Partner History
Medical problems: Take routine medications or supplements? Has he had a semen analysis? Yes No History of hernia or testicular surgery Yes No When? Results? Has he seen a Urologist? Yes No Exposure to chemicals/radiation/toxins? Yes No Urologist’s Name/Location: Previously fathered a child? Yes No Trouble with erections? Yes No Age of children: Does he currently smoke? Yes No Currently or has ever used any type of steroids? Yes No Use marijuana or other drugs? Yes No Any illnesses/fevers in the past 3 months? Yes No History of sexually transmitted diseases? Yes No Planning for a baby involves some very important decisions. Among those is whether to test yourself for certain
genetic traits that can potentially cause disease in your offspring. While there are many rare inherited diseases, a
few occur with enough frequency in certain populations to warrant screening for them before you become
pregnant.
Screening for genetic diseases usually involves nothing more than a simple blood test. A “screening test” means
that the test is designed to detect an abnormality in most affected individuals. In other words, a negative result
does not guarantee that you are not affected. It does, however, dramatically reduce your risk.
A positive result from a genetic disease screening test may prompt further diagnostic testing and is normally
followed by formal counseling about your reproductive options. Positive test results have implications for you,
your offspring and your extended family members. Therefore, it is very important to consider how a positive
screening test result would affect you before you complete the test.
The following is a list of currently-recommended genetic disease screening tests based on specific ethnic
backgrounds.
African
American Asian

Ashkenazi Jewish (Eastern European)


Caucasian
Cajun/French
Canadian

Hispanic
Cystic

Cystic Fibrosis
Cystic fibrosis (CF) is a hereditary disease that affects mainly the lungs and digestive system, causing progressive disability, recurrent infections, and usually early death. CF does not affect intelligence or appearance. Average life expectancy is around 37 years. Approximately 1 in 25 Caucasians carry this gene defect, as well as 1 in 46 Hispanics, 1 in 65 African Americans and 1 in 90 Asians. If you are a carrier, you have a 50% chance of your child being a carrier, which would not be affected. If your partner is also a carrier, you have a 25% chance of having a child with the disease. Current testing can determine if you carry the gene(s) responsible for this disease. Detection rates (the chance of picking up an affected gene if it exists) depend upon your ethnic background and vary from 30-97%. .
Sickle Cell Anemia/Alpha-thalassemia/Beta-thalassemia
These are a group of inherited blood disorders that causing varying degrees of anemia (low blood count) or episodes of body pain. In some cases, the genetic disease can be lethal. The chance of carrying one of these genes (in a population at risk) varies from 1/10 to 1/200. Tay-Sachs/ Canavan Disease/Familial Dysautonomia
Fanconi Anemia, group C/Gaucher disease, type 1
Niemann-Pick, type A Bloom Syndrome/Mucolipidosis IV
Included in this group are disorders of the central nervous system (brain) and immune system. Many are lethal. The chance of carrying one of these genes (in a population at risk) varies from 1/13 to 1/100.  I have read the above including specific risks related to my ethnic background and DO wish to pursue
preconception genetic screening at this time.  I have read the above including specific risks related to my ethnic background and DO NOT wish to
pursue preconception genetic screening at this time.

__________________________
_________________________ Printed Name (Patient) _________________________ __________ Signature _________________________ Printed Name (Partner) Marin Fertility Center
1100 S. Eliseo Dr, Suite 107, Greenbrae, CA 94904 Address: ____________________________________________________________________________________________________ Home Phone: (______)_______-__________ Cell Phone: (______)_______-_________ Other: (______)_______-__________ Email: _______________________________________ *Any restrictions for contacting you? ( ) No ( ) Yes If yes explain restrictions for contacting: ________________________ Driver’s License #:_________________________________________________________________ State:______________________
Birthdate: _______/_______/__________ Age: ______ Sex: ( ) Female ( ) Male SS#: ________-________-__________
Marital Status: ( ) Single ( ) Married to: _________________________________ ( )Other: ________________________________
Allergies: Foods:__________________________________________ Drugs:_____________________________________________
Patient’s Employer: ______________________________________________ Occupation: _________________________________
Work Phone:(______)_______-__________ Ext.___________ *Is it okay to call you at work? ( )Yes ( )No
Address:____________________________________________________________________________________________________
Emergency Contact:
(Not in your household) __________________________________________________ Relationship: _________________________
Home Phone: (______) _______-__________ Cell Phone: (______) _______-_________ Other: (______) _______-__________
Address:____________________________________________________________________________________________________
Primary Care Physician______________________________________________________ Phone: (______) _______-__________
Primary Health Insurance Company____________________________________________________________________________
Insurance Claims Mailing Address______________________________________________________________________________

Policy #:______________________________ Group #:___________________________ Ins. Phone: (______) _______-__________ Referral Required? ( ) No ( ) Yes *Do you have a Co-pay? ( ) No ( ) Yes, $_______________________
Insured: Name:________________________________ DOB:______/______/________ Employer: ___________________________
Secondary Health Insurance Company__________________________________________________________________________
Insurance Claims Mailing Address______________________________________________________________________________

Policy #:______________________________ Group #:___________________________ Ins. Phone: (______) _______-__________ Referral Required? ( ) No ( ) Yes *Do you have a Co-pay? ( ) No ( ) Yes, $_______________________
Insured: Name:________________________________ DOB:______/______/________ Employer: ___________________________
I understand that office visit charges are payable on the day of service is rendered. I authorize Napa Valley Fertility Center to bill my insurance company regardless of
insurance coverage, I am responsible for all bills being paid in a timely manner.
Signature: ______________________________________________________________________ Date: ______/______/________
Marin Fertility Center
1100 S. Eliseo Dr., Suite 107, Greenbrae, CA 94904 CONSENT TO USE AND DISCLOSE HEALTH INFORMATION

Persuant to the requirements that are found in the Health Insurance Portabilitiy and
Accountability Act of 1996 (HIPPA), the following is offered for your information and consent.
Please be aware that it is this office’s policy to require your reading and signing of this consent
form prior to the provision of treatment or any other medical services. If you have any questions,
please ask for the privacy official in this office.
I, ____________________________________________, do hereby consent to use and disclosure
of my individual identifiable health information (IIHI) by the Marin Fertility Center for the
purpose of providing treatment to me, receiving payment from responsible parties for the health
care services rendered by my physician, and/or engaging in the health care operations, such as
office management, credentialing case management, and quality assessment.
I understand that Marin Fertility Center’s Notice of Privacy Practices describes in more detail
the types of uses of disclosure of health information involved in treatment, payment of health care
operations, and that I have been given an opportunity to read this document prior to signing this
consent. I also understand that I may receive a paper copy of this Notice upon request.
I understand that Marin Fertility Center, has the right to change its privacy practices and that I
can obtain a copy of the revised Notice by writing to the physician.
I understand that if I chose to not sign this consent, my physician may withhold medical services,
other than emergency services.
I understand that I have the right to request a restriction on my physician’s use or disclosure of
any and/or all health information to any/all locations, entities or persons. I further understand that
my physician is not obligated to agree to the request. However, if my physician does agree to this
request, the agreement will become binding.
I understand that I have the right to revoke this consent, in writing, at any time, except to the
extent that my physician has relied on this consent, and that revocation will become effective on
the date it has been received by the Marin Fertility Center and will apply to uses and
disclosures of health information after the date of receipt.
Patient Signature:_______________________________________ Date:__________________

Source: http://www.marinfertilitycenter.com/resources_files/New%20Patient%20Packet%20MFC.pdf