Past Medical History
If you have selected any of the previous boxes, enter details below:
Past Surgical History
If you have been hospitalized for any reason (excluding surgeries listed above and deliveries), please describe here:
Please list your current medications, including vitamins and herbs, and their respective doses:
Please list any allergies to medications (or latex) that you may have:
Family Planning History
For above, please add details(dates of use, types or names) below:
If yes, please enter date or dates.
If you chose any of the previous options, please describe the condition and the family member's relationship to you:
Have you used any of the following:
If yes, servings/day and type
If yes, how much, or how many packs per day, and how many years have you been smoking?
If checked, please describe below:
Please describe each test, date it was performed, and results below:
Review of Systems
Check any of the following that you are CURRENTLY experiencing:
Please describe below:
Prior Fertility Testing
Intercourse without contraception
Describe tests, dates, and results below:
Please describe above.