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What to expect  infertility second opinion  
FAQs  infertility second opinion  
Policy and Procedures  infertility second opinion  
Step 1: Complete Form  infertility second opinion  
Step 2: Authorize Consultation  infertility second opinion  
 infertility second opinion
Please take time to accurately complete the Second Opinion Form in order to assure your complete satisfaction. After completing Step 1(the Second Opinion Questionnaire below) and Step 2 (Authorization), please allow 5 business days for the Center for Human Reproduction to respond to your Second Opinion Consultation request.
Female Name:   *
Date of Birth:

   *(mm/dd/yyyy)
Male Name:   *
Date of Birth:   *(mm/dd/yyyy)
Address 1:
Address 2:
City:
State:
Zip:
Home Phone:
Daytime Phone:   *
email:   *
Alternate Phone:
Referred from:   A friend   Internet
Prior Infertility History:
How many years have you been trying to become pregnant:
Have you ever seen a physician for infertility?
  Yes
  No
 
If yes, list physician name, address and phone number.
Physician #1:
Physician #2:
Physician #3:
 
If yes, list last date you visited each physician.
Physician #1:
Physician #2:
Physician #3:
 
If yes, what diagnosis was reached?
Diagnosis:
 
If yes, what tests were performed?
Tests:
 
If yes, what treatment did you receive?
Treatment:
 
If yes, what medication and amounts did you receive?
Medications:
 
Did you ever conceive with fertility treatment?
  Yes
  No
 
If yes, did you have singleton or multiple?
 
How many times have you had repeated pregnancy loss:
 
List last four pregnancy outcomes:
Date Outcome if
miscarriage		 if
miscarriage		 if
miscarriage		 if
miscarriage
 
Are you seeking a second opinion:
  Yes
  No
If yes, please explain why:
Is there any other reason(s) for consultation:
 

Menstrual History:
(please answer the following questions about your menstrual cycle)
How old were you when you first began to menstruate:
10
11
12
13
14
15
Other Enter Other:
How many days are there (usually) between one period to the next?
  26-28
  29-32
  Other  Enter Other:  
How many days do your periods usually last?
  2-3
  4-5
  6-8
  Other  Enter Other:
Do you ever experience mid-cycle bleeding?
  Yes
  No
Your last menstrual period started on what date?
Grade your pain level you experience with your menstrual period as:
  Very Low
  Low
  Moderate
  High
  Very High
Would you describe your menstrual cycle as:
  Regular
  Irregular
In general, how heavy is your menstrual flow?
  Light
  Moderate
  Heavy
  Very Heavy
Have you had a Pap Smear within the past 12 months?
  Yes
  No
Was result of your Pap Smear within normal limits?
  Yes
  No
Have you had a mammagram within the past 12 months?
  Yes
  No
Was result of your mammagram within normal limits?
  Yes
  No
Have you ever taken, or are you currently taking oral contraceptives?
  Yes
  No
If yes, what brand and for how long?
What methods of contraceptive have you used? Please list and date last used:
Have you ever experienced pain with sexual intercourse?
  Yes
  No
If yes, please describe the pain:

Female Medical/Surgical History:

Have you been surgically sterilized?
  Yes
  No
If yes, please describe:
Have you had any other surgeries in the past?
  Yes
  No
If yes, please indicate what surgeries you have had:
Have you ever been hospitalized for anything other than the above listed surgeries?
  Yes
  No
If yes, please tell us why you were hospitalized:
Are you allergic to any medications?
  Yes
  No
If yes, please tell us what medication you're allergic to:
Do you have any dietary restrictions?
  Yes
  No
If yes, what are your dietary restrictions, and for what reason?
Do you take any supplemental vitamins or herbal remedies on a continual basis?
  Yes
  No
If yes, please list what vitamins or herbal remedies you are taking:
Do you take any prescription or over the counter medication on a regular or continual basis?
  Yes
  No
If yes, please list what medication you are currently taking:
Do you exercise regularly?
  Yes
  No
Have you ever been told in the past, that you have had any of the following? (check all that apply):
Abnormal Pap Smear Hepatitis A, B or C
Acne Herpes Simplex Virus I or II
AIDS/HIV High Blood Pressure
Allergies Hypertension
Anemia Intolerance to hot/cold
Alzheimer's Disease Jaundice
Anorexia Kidney Disease
Appendicitis Loss of Libido
Arthritis Loss of Scalp Hair
Autoimmune Disorder Measles
Colitis Multiple Sclerosis
Blocked Fallopian Tubes Neurologic Problems
Breast Cancer Nongonococcal Urethritis
Breast Masses Ovarian Cancer
Breast Secretions Ovarian Cysts
Bronchitis Pain with Intercourse
Cancer Parasitic Infections
Cervical Cancer Pelvic Inflammatory Disease
Chlamydia Pneumonia
Chronic cough Polycystic Ovarian Syndrome (PCOS)
Chronic Pelvic Pain Poor Sense of Smell
Condyloma Psychiatric Care
Diabetes Rheumatic Fever
Endocrine Disease Scarlet Fever
Endometriosis Seizures
Gonorrhea Sexually Transmitted Disease
Epilepsy Syphilis
Excessive Hair Growth Thyroid Problems
Excessive Sweating Transfusion Problems
Excessive Weight Change Tuberculosis
Fibroids Ulcers
Dizziness Ureaplasma/Mycoplasma
Frequent Headaches Vaginitis
Gallbladder Disease Visual Disturbances
Heart Disease
Have you ever been excluded from blood donation?
  Yes
  No
If yes, please explain when and why:

Psychological History:

Have you ever sought counseling for depression or emotional problems?
  Yes
  No
Have you ever taken antidepressants for more than three months at a time?
  Yes
  No
Have you ever been diagnosed as having any of the following (please check all that apply)
Depression
Schizophrenia
Manic Depression
Obsessive-Compulsive Disorder
Mania
Anorexia or Bulimia
Self Mutilation
Have you ever received Pituitary derived growth hormone?
  Yes
  No

Family History

Are there any genetic abnormalities or birth defects in family?
  Yes
  No
If yes, please describe:
Relative Alive? Present age or age of death Any Medical Problems
Mother   Yes
  No
Maternal Grandmother   Yes
  No
Maternal Grandfather   Yes
  No
Father   Yes
  No
Paternal Grandmother   Yes
  No
Paternal Grandfather   Yes
  No
Sibling 1   Yes
  No
Sibling 2   Yes
  No
Your Own Child 1   Yes
  No
Your Own Child 2   Yes
  No
Please tell us if any member of your family has any of the conditions listed below. Check all that apply and indicate who in your family has the condition.
Condition Self FamilyWho in the Family?
Cleft PalateNoYesNo
Spina BifidaNoYesNo
Thyroid DiseaseNoYesNo
ClubfootNoYesNo
Mental RetardationNoYesNo
Down's SyndromeNoYesNo
Cystic FibrosisNoYesNo
Marfan SyndromeNoYesNo
AlbinismNoYesNo
Muscular DystrophyNoYesNo
Cancer (indicate type)NoYesNo
SchizophreniaNoYesNo
Clinical DepressionNoYesNo
Obsessive-Compulsive DisorderNoYesNo
ManiaNoYesNo
Tay Sachs DiseaseNoYesNo
Canavan's DiseaseNoYesNo
Hemolytic AnemiaNoYesNo
BlindnessNoYesNo
Hearing ImpairmentNoYesNo
Color BlindnessNoYesNo
Heart DiseaseNoYesNo
Parkison's DiseaseNoYesNo
HemochromatosisNoYesNo
High CholesterolNoYesNo
Sickle Cell AnemiaNoYesNo
HemophiliaNoYesNo
Huntington's DiseaseNoYesNo
DiabetesNoYesNo
Multiple SclerosisNoYesNo
Altzheimer's DiseaseNoYesNo
InfertilityNoYesNo
Recurrent MiscarriageNoYesNo
Liver DiseaseNoYesNo
High Blood PressureNoYesNo
AsthmaNoYesNo
EpilepsyNoYesNo
Tourette's SyndromeNoYesNo
Still Born BabiesNoYesNo
Sudden Infant Death DefectsNoYesNo
Death before age 40NoYesNo
Addiction (indicate type)NoYesNo
Clinical OsteoporosisNoYesNo
Ethnicity (check all that apply):
Aborigine African
Asian/Indian Chinese
Caucasian Hispanic
Indonesian Mediterranean
Native American West Indian
Jewish-Ashkenasi Jewish-Sephardic
Other Enter Other:  
Please select your ancestry and provide the
percentage. You can add up to 8 ancestries.
  %  
  %  
  %  
  %  
  %  
  %  
  %  
  %  

Social History

Tobacco (Check all that currently apply):
I currently smoke
I am a heavy smoker
I used to smoke but no longer do
I have never smoked cigarettes
Alcohol
  I never drink alcohol
  I drink    times per week
  I rarely drink alcohol (less than twice a year)
Drug usage:
  I have never used illegal drugs
  I have tried illegal drugs at least once in the past
  I used to do drugs regularly but don't anymore
  I am currently using one or more of the following:
  Enter usages:  
Have you ever used injectable drugs?
  Yes
  No
If yes, when did you last use injectable drugs?
Describe your profession:

Male History:

(please answer the following questions about the male partner if appropriate)
Any prior children from other partners?
  Yes
  No
Are you aware of any health problems with yourself?
  Yes
  No
If yes, please indicate those problems:
Ethnicity (check all that apply):
AborigineAfrican
Asian/Indian Chinese
Caucasian Hispanic
Indonesian Mediteranean
Native American West Indian
Jewish-Ashkenasi Jewish-Sephardic
Other
Are there any genetic abnormalities or birth defects in family?
  Yes
  No
If yes, please describe:
Is there a prior semen analysis?
  Yes
  No
If there was a semen test, was it normal or abnormal?
  Normal
  Abnormal
If abnormal, please list defects:
Are you aware of any other health problems in your self, family or previous sexual partners that you have not already disclosed?
  Yes
  No
If yes, please indicate those problems you are aware of, that you have not already disclosed to us in this document:

 

I understand that the answers used in this questionnaire will be used to determine an appropriate treatment plan for me. By clicking Submit, I hereby certify that my answers and explanations, which were voluntarily given in this questionnaire, are correct. I understand that the answers used in this questionnaire will be used to determine an appropriate treatment plan.
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