RMIA New Patient Health and History

Patient name*

First NameLast Name
Patient occupation*
Patient Birth Date*

MonthDayYear
Patient email

Confirmation Emailexample@example.com
Patient/couple*
Reason for visit?
Length of unprotected intercourse with current partner (heterosexual couples only):
When was your first infertility evaluation or treatment?
Have you ever been given a specific infertility diagnosis?*
Who is your Ob/Gyn?*
If not referred by your Ob/Gyn, how did you hear about us?*
Patient Height and weight (click arrows below if feet/inches/lbs is not showing)*

Which of the following racial/ethnic groups do you, the female patient most closely identify? Check all that apply*

	Check all that apply
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Refused
Unknown

Have you ever been pregnant?*
Please specify
Have you attempted pregnancy in a previous relationship?*
Please specify
Have you had TWO or more miscarriages?*

Previous pregnancies - please list all pregnancies, first to last, including miscarriages, abortions and tubal pregnancies

	Date pregnancy delivered or ended	With current partner?	How long to conceive?	Pregnancy duration?	Outcome	Infertility treatment?	Gender	Birth Weight	Name of Child
1
2
3
4
5
6
7

Did you undergo fertility treatment to achieve any of your pregnancies?*
Have you or your partner had any testing (blood work, other) to test for causes of recurrent miscarriages?*
Were any of your pregnancies or deliveries associated with medical problems, complications (infection, need for blood transfusion) or birth defects?*
Please specify
Are you currently breastfeeding?

YesNo
When did you stop?

Have you had any hormonal tests?*
Please specify

Have you had any of the following tests/procedures?*

	Check all that apply	Approx dates and findings
HSG (hysterosalpingogram)
Pelvic ultrasound study
Sonohysterogram
Laparoscopy
Hysteroscopy
D&C
Laparotomy
Surgery to remove ovary/myoma
NONE of the above

Please provide pertinent details regarding above
Have you ever been treated with clomiphene citrate (Clomid/Letrozole)?*
Please briefly describe (dates, number of cycles with and without inseminations [IUIs], use of ultrasound to monitor response, whether hCG [or Ovidrel] was used to trigger ovulation, name[s] of centers/managing physician):
Have you ever been treated with injectable fertility drugs (such as Bravelle, Menopur, Gonal-f, Follistim) in cycles not involving in vitro fertilization (IVF)?*
Please briefly describe (dates, number of cycles with and without inseminations [IUIs], name[s] of centers/managing physician):
Have you ever undergone IVF treatment?*
Please briefly describe (dates, number of cycles including frozen embryo transfers, outcomes, name[s] of centers/managing physician):
Age at time of 1st period:
What were your periods like as a teenager?
First day of most recent period: *
First day of period before that:
Describe your cycles when not taking medications that affect your cycles (such as birth control pills or fertility drugs): *
What is the usual range of days from the 1st day of one period to the 1st day of the next?
How long do your periods generally last? *
Are your periods usually similar from one to the next?*
Please specify
Do you have spotting or bleeding between periods?*
Please specify
Do you consider your periods to be abnormal? *
Please specify
Do you have cramping with your periods?*
Describe any medications used for cramping:
Do you usually have premenstrual symptoms, such as breast symptoms or mood changes?*
Have your periods changed over the last year? *
Please specify
Have you done BBT charting or used ovulation detection kits? *
Please specify
Have you recently used any hormonal medications that can affect your cycles, such as birth control pills, Provera or Lupron?*
Please specify
Have you ever taken birth control pills to make your cycles regular?*
Have you ever taken any medications to bring on a period, such as Provera?*

Please check birth control measures you have used:*

	Check all that apply	Approximate dates
Birth control pills
Other hormonal birth control such as Depo-Provera, NuvaRing , Ortho Evra Patch
IUD
Diaphragm
Condoms
Rhythm, partner withdrawal
Other
NONE of the above

Do you currently have an IUD in place?
Which IUD do you have in place?
Why do you have an IUD in place right now?
Ex: Bleeding, prevent pregnancy
Please specify any problems you have had with any form of birth control?

Smoking history*

Never or essentially never smoked cigarettesPreviously smokedCurrently smoke
How many did you smoke per day?
How many years had you smoked?
When did you quit?
How many do you smoke per day?
How many years have you smoked?

Other habits*

	check all that apply	Please describe number per day
Alcohol
Caffeine
Recreational/illicit drugs
Vaping
Have you ever been in a program for treatment of alcohol/substance abuse
NONE of the above

Has your weight changed significantly over time?*
Please specify
Briefly describe average weekly physical exercise*

MALE PARTNER INFORMATION
Male name*

First NameLast Name
Occupation*
Date of birth*

MonthDayYear
Date
Current age*
Prior pregnancies in a previous relationship?*

Which of the following racial/ethnic groups do you, the male patient, most closely identify? Check all that apply*

	Check all that apply
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
Refused
Unknown

Previous marriage or long-term relationship?*
Years of prior pregnancies
Previous unsuccessful attempts to conceive with another partner?*

Current medications (include prescription & over-the-counter, herbal, vitamin & other supplements)*
Any allergies or adverse reactions to medications?*
Please list and describe reactions
Any food (peanuts, eggs, etc.) allergies or latex allergy/sensitivity?*
Please list and describe reactions
Please describe any medical illnesses, hospitalizations, or surgery not described above

Have you had a fever in the last 3 months?*
Are you exposed to prolonged heat, radiation, or harmful chemicals in the workplace?*
Please specify
Do you use hot tubs or steam baths?*
Please specify
Please provide pertinent details regarding above
Smoking history*

Never or essentially never smoked cigarettesPreviously smokedCurrently smoke
How many did you smoke per day?
How many years had you smoked?
When did you quit?
How many do you smoke per day?
How many years have you smoked?

Other habits*

	check all that apply	Please describe number per day
Alcohol
Caffeine
Recreational/illicit drugs
Vaping
Have you ever been in a program for treatment of alcohol/substance abuse
NONE of the above

FOR COUPLES ONLY
How frequently do you have sexual intercourse?
Do you have any pain or discomfort with intercourse?*
Do you or your partner have problems initiating or completing sexual intercourse?*
Please specify
Do you use a lubricant for intercourse?*
What lubricant do you use?
Do you plan intercourse for a specific time of your cycle?*
How do you plan for this?
Do you douche before or after intercourse?*
Do you feel that your infertility problems are causing stress between you and your partner?*
Do you feel that your infertility problems are interfering with sexual satisfaction? *

Please upload/take photos of VALID photo ID(s) and VALID insurance card(s)

You may disregard if you already uploaded these during the registration process, we are currently in a software transition. THANK YOU
Photo of patient's valid drivers license/picture ID - PLEASE MAKE SURE ALL TEXT IS LEGIBLE
Photo of patient's current insurance card (Front of card) - PLEASE MAKE SURE ALL TEXT IS LEGIBLE
Photo of patient's insurance card (Back of card) - PLEASE MAKE SURE ALL TEXT IS LEGIBLE
Photo of partner's valid drivers license/picture ID - PLEASE MAKE SURE ALL TEXT IS LEGIBLE
Photo of partner's current health insurance card (Front of card) - PLEASE MAKE SURE ALL TEXT IS LEGIBLE
Photo of partner's insurance card (Back of card) - PLEASE MAKE SURE ALL TEXT IS LEGIBLE
Phew! That was a lot of work! You're almost done! The next segments are to obtain the following consents:

1) Medical record release forms

2) Horizon Genetic Screening consent - you will need to accept or decline testing

3) HIPAA consents: this is so we (RMIA) have authorization to discuss medical testing/history in the presence of your partner. Each person will need to sign a consent.

You will receive emailed copies of our clinic policies and all of these consents after your submission is complete.

Thank you for your patience and cooperation! Click submit below to go to final segment of our New Patient Packet.
Should be Empty:

	Check all that apply	If yes, please describe dates and treatment measures
Chlamydia
Gonorrhea
Syphilis
HIV/AIDS
Genital warts/HPV
Herpes
Hepatitis B
Hepatitis C
NONE of the above

	Check all that apply	Approx dates and treatment measures
Yeast/candida
Bacterial vaginosis
Trichomoniasis
Other
NONE of the above

	Check all that apply	Please describe how diagnosis was made and approx dates of any treatment (medical or surgical)
Congenital uterine abnormality
Uterine myomas/fibroids
Uterine/cervical polyps
Endometriosis
Ovarian cysts
Ovarian tumors
NONE of the above

	Check all that apply	If yes, please describe and include treatment measures
Acne/oily skin
Abnormal hair growth
Frontal or other hair loss
Darkened skin discoloration along neck, under breasts or in armpit areas
Leakage of breast milk or other discharge unrelated to pregnancy
Hot flashes or night sweats
Polycystic ovarian syndrome
Premature ovarain failure or premature menopause
Diabetes
Thyroid problems
NONE of the Above

	Check all that apply	Please specify
Any hormonal disorder
Anemia
Tendancy to bleed or bruise easily
Blood clots/coagulation disorder
Kidney disease
Breast problem/biopsy
Psychiatric/psychological disorder
Heart problems/high blood pressure
Pulmonary problems
Joint problems
NONE of the above

	Check all that apply	Please specify
Cancer
Thyroid disorder
Diabetes
Early menopause
Polycystic ovarian syndrome
Endometriosis
Infertility
Recurrent miscarriages (2 or more)
Intellectual disability
Birth defects/stillbirths
Known genetic disorders (eg, cystic fibrosis)
Bleeding disorders
Blood clots/coagulation disorders
Neurologic disorders
Psychiatric disease
Early heart disease
Arthritis/autoimmune disease
NONE of the above

	Check all that apply	Please specify
Any hormonal disorder
Chemotherapy or radiation for cancer
Undescended testis
Blood in the ejaculate
Recurrent urinary tract infection
Prostatitis
Mumps after puberty
Testicular injury/swelling
Decreased libido
Erectile dysfunction
Hernia surgery
NONE of the above

	How many biological sisters/brothers?	Do any of them have any health problems or infertility?
Sisters
Brothers
Siblings children (nieces/nephews)

	How many biological sisters/brothers?	Do any of them have any health problems or infertility?
Sisters
Brothers
Siblings children (nieces/nephews)

MALE PARTNER INFORMATION

FOR COUPLES ONLY

Please upload/take photos of VALID photo ID(s) and VALID insurance card(s)