Tell us a bit about yourself.

In case I require a follow-up consultation with a physician,

I was referred to CHR by:

Female History

PLEASE IGNORE THIS SECTION IN ABSENCE OF A FEMALE PARTNER

Please tell us

How many times have you been pregnant?

Some questions about your menstrual period:

Is your menstrual pattern:

PAP Smear:

Result:

Mammogram:

Result:

Have parents, grandparents or siblings of yours been diagnosed with:

Breast cancer?

Ovarian cancer?

Have you ever had any of the following?

If YES, please explain:

Are you currently on any medications?

Are there medical or genetic problems in your family?

If YES, please explain:

Where is your family from in the world?

Do you consider yourself:

Is your ethnicity:

Tell us whether you

Are

Please tell us

Are you currently on any medications?

Have you ever been hospitalized, significantly injured, had surgery, received a medical treatment for longer than 2 weeks, suffer from unexplained symptoms, have been diagnosed with a disease (even if currently untreated), including psychiatric conditions?

Are there medical or genetic problems in your family?

If YES, please explain:

(A GENETIC PROBLEM IS DEFINED AS EITHER BIRTH OF A CHILD WITH BIRTH DEFECTS OR OCCURRENCE OF A DISEASE IN MORE THAN ONE GENERATION)

Where is your family from in the world?

Do you consider yourself:

Is your ethnicity:

Tell us whether you

Do you have embryos or eggs frozen at another IVF center?

PRIOR FRESH IVF CYCLE HISTORY

PLEASE LIST YOUR IVF CYCLE IN ORDER FROM 1 ‐ X, AND TELL US FOR EACH CYCLE THE APPROXIMATE DATE STARTED, THE CENTER WHERE PERFORMED (IF POSSIBLE THE NAME OF TREATING PHYSICIAN), WHETHER THE CYCLE REACHED EGG RETRIEVAL, HOW MANY EGGS WERE OBTAINED, HOW MANY FERTILIZED, WHETHER YOU HAD AN EMBRYO TRANSFER, IF NOT, WHY NOT, HOW MANY EMBRYOS WERE TRANSFERRED, WHETHER AND HOW MANY EMBRYOS WERE CRYOPRESERVED, AND WHAT YOU WERE TOLD ABOUT THE QUALITY OF TRANSFERRED EMBRYOS. PLEASE DO NOT LIST HERE FROZEN‐TAHAWED IVF CYCLES.

Add Cycle

Did any of your IVF cycles result in freezing of embryos?

Did any of your IVF cycles involve culturing your embryos to blastocyst stage (day‐5)?

Did any of your IVF cycles involve the use of preimplantation genetic diagnosis or screening (PGD/PGS)?

Were any of your IVF cycles accompanied by complications, hospitalizations or other unusual events?