infertility second opinioninfertility second opinioninfertility second opinion
Conditions We Treat  conditions we treat  
Special Programs  special programs  
Asst. Reproductive Technology  ART  
General Fertility Programs  fertility programs  
Pregnancy Rates  pregnancy rates  
Patient Financial Services  financial services  
CHR Handbook  chr handbook  
New Patient Questionnaire  chr handbook  
What sets CHR apart from the rest?  ovarian infertility  

At CHR, we ask our new patients to fill out the initial questionnaire online. This will save you time in the waiting room when you visit us for the first time. If you have not made your appointment with one of our physicians, please do so before completing this questionnaire. You can set up your appointment by speaking to our receptionist at 212-994-4400.

In this questionnaire, "You" refers to the female patient, and "your partner" refers to the male patient. Please take time to accurately complete this questionnaire. When you are satisfied with your answers, please click the "Submit" button at the bottom of the page. Your answers will be sent to CHR, where our physician(s) will be able to review them prior to your appointment.


CHR New Patient Questionnaire
Female Patient
First Name:   *
Last Name:   *
email:   *
Retype email:
Occupation:   *
Age:   *
Male Patient
First Name:   *
Last Name:   *
Occupation:   *
Age:   *
Referral Source:
   Self
   Friend
   Physician
   Relative
   Insurance
   Internet
Other   Enter Other:  
Please provide referring doctor information:
Doctor's Name:
Doctor's Address:
Doctor's City:
Doctor's Address State:
Doctor's Address ZIP:
Doctor's Address Country:
Doctor's Phone:
Doctor's Fax:
Doctor's Email:

Have you been treated for infertility before?

Female    Yes Doctor Name:
   No Diagnosis:
Male    Yes Doctor Name:
   No Diagnosis:
How long have you been attempting pregnancy? months
How many times have you been pregnant?
How many children do you have?
My current partner is the father of ALL of my children.
My current partner is the father of SOME of my children.
My current partner is the father of NONE of my children.

If you have been pregnant, tell us about your pregnancies:

Were your pregnancies uneventful? Yes No
If you checked "No" above, please describe in what way:
I delivered children on (dates):

Tell us about your gynecologic history:

I had my first period at age:
The starting date of my last period was: (MM/DD/YY)
My periods are: Regular Irregular
If regular, how many days do you have between your periods?
If irregular, how many periods do you have in a year?
How many days do you usually bleed?
Have there been any recent changes to your period? Yes No
If you checked "Yes" above, please describe how it has changed:
Do you bleed or spot between periods? Yes No
Do you suffer cramps during your periods? Yes No
How severe is your cramps?
What was the date of your last pap smear?
The results were: Normal Abnormal
If abnormal, please describe the abnormal findings:

Have you had any of the following? If so, please indicate date (month and year).

Syphilis Yes No Date:
Gonorrhea Yes No Date:
Chlamydia Yes No Date:
Herpes Yes No Date:
Ovarian Cysts Yes No Date:
Pelvic Infection Yes No Date:
Appendicitis Yes No Date:
Endometriosis Yes No Date:
hirsutism (excess hair) Yes No Date:
Acne Yes No Date:
Have you used contraceptives? Yes No
If yes, please list the contraceptive(s) and the dates taken:
How many times a week do you have intercourse?
For the past how many months have you had timed intercourse around ovulation? month(s)
Have you ever had hepatitis? Yes No
Have you engaged in high-risk behaviors? Yes No

Tell us about the medical history, birth defects, mental retardation and genetic diseases in both of your families.

Which Side? Problem Relative
My Side
Partner's Side
My Side
Partner's Side
My Side
Partner's Side
My Side
Partner's Side
My Side
Partner's Side
My Side
Partner's Side
My Side
Partner's Side
My Side
Partner's Side
My Side
Partner's Side
My Side
Partner's Side

You DO NOT have to answer these two questions about your ethnicity.

Your Ethnicity: Your Partner's Ethnicity:
Caucasian Caucasian
African American African American
Asian American Asian American
Native American Native American
South Pacific Islander South Pacific Islander
Hispanic Hispanic
Other: Other:

Tell us about procedures, hormone and antibody tests you have had for infertility:

Description Date (MM/DD/YY) Normal/Abnormal
Basal Body Temperature Normal Abnormal
Post-Coital Test Normal Abnormal
Endometrial Biopsy Normal Abnormal
LH/FSH Laboratory Evaluation Normal Abnormal
TSH/T4 Laboratory Evaluation Normal Abnormal
Prolactin Laboratory Evaluation Normal Abnormal
Estrogen Laboratory Evaluation Normal Abnormal
Progesterone Laboratory Evaluation Normal Abnormal
Testosterone Laboratory Evaluation Normal Abnormal
DHEAS Laboratory Evaluation Normal Abnormal
Sperm Antibody Laboratory Evaluation Normal Abnormal
Other Hormone or Antibody Tests Normal Abnormal
Hysterosalpingogram (most recent) Normal Abnormal
Hysteroscopy (most recent) Normal Abnormal
Laparoscopy (most recent) Normal Abnormal
Pelvic Surgery Normal Abnormal

Tell us about procedures, hormone and antibody tests your partner has had for infertility:

Description Date (MM/DD/YY) Normal/Abnormal
Semen Analysis (most recent) Normal Abnormal
Semen Culture (most recent) Normal Abnormal
LH/FSH Laboratory Evaluation Normal Abnormal
TSH/T4 Laboratory Evaluation Normal Abnormal
Prolactin Laboratory Evaluation Normal Abnormal
Testosterone Laboratory Evaluation Normal Abnormal
Sperm Antibody Laboratory Evaluation Normal Abnormal
Other Hormone or Antibody Tests Normal Abnormal
Tell us about your previous infertility treatments (check all that apply):
Intrauterine Inseminations Donor Sperm
Gamete Intrafallopian Transfer (GIFT) Zygote Intrafallopian Transfer
Other Infertility Treatment
If you have had other forms of infertility treatments, please describe the treatments:

Tell us about your previous infertility stimulation medication(s). Because dosage may change, two lines are provided for each medication. List the most recent first, then the dosage before that.

Medication Number of Cycles Dosage
Clomophene
also known as Clomid or Serophene
hCG (Human Chorionic Gonadotropin)
also known as Proafasi, HP or APL
hMG (Human Menopausal Gonadotropin)
also known as Personal or Repronex
FSH (Follicle Stimulating Hormone)
also known as Follistim or Gonal-F
Bromocriptine
also known as Parlodel
Danocrine
also known as Danazol
GnRH Agonist
also known as Lupron, Depo Lupron or Synarel
GnRH Antagonist
also known as Antagon or Ganirelix Acetate
Predisone
or other cortisone-like medication
Privacy Policy | Terms of Use | Designed and maintained by BusiMed, Inc. | © 2008