New Patient Form

 

Instructions

Thank you for choosing Reproductive Endocrinology Associates of Charlotte (REACH). So that your first appointment is as productive as possible, we have created the following electronic form for you to complete at your convenience. Your information will be stored safely.
We take your personal privacy very seriously and will not use your information except as clearly permitted or required by federal and state laws.

As is often the case in gathering comprehensive medical information, this form will require a time investment for completion. Please note, that once you begin filling out the form, you must complete in its entirety before submission. This information will allow our doctors to better assess your personal situation, thus increasing your chance of successful treatment.

We appreciate you taking the time to prepare for your appointment.

Again, thank you for choosing REACH!

1. General Information

Fields with asterisks (*) are required. Please complete all of these fields.

feet inches

 

How many months have you been sexually active with your current partner without using contraception?  
How many months have you been attempting pregnancy?  

2. Pregnancy History
I have been pregnant:
1.)
years months
months
2.)
years months
months
3.)
years months
months
4.)
years months
months
5.)
years months
months

3. Menstrual/Gynecological History

4. Contraceptive History
I have used contraceptives:
1.)
 to 
2.)
 to 
3.)
 to 
4.)
 to 
5.)
 to 

5. Sexual History

Fields with asterisks (*) are required. Please complete all of these fields.


6. Medical History

7. Medical Allergies
I am allergic to some medications:
I am allergic to latex:

8. Medications
I take prescription medications:
I take vitamins or supplements:
1.)
to
2.)
to
3.)
to
4.)
to
5.)
to

9. Surgical History/Previous Procedures
I have had at least one operation or procedure:
1.)
2.)
3.)
4.)

10. Social History
Vigorous Exercise:
1.)
2.)
3.)
4.)

11. Family History

12. Partner History
I have a partner:
-

13. Partner Social History
Vigorous Exercise:
1.)
2.)
3.)
4.)

14. Fertility Testing History

15. Fertility Treatment History

16. Insurance Information
I am currently covered by insurance: *
1.)
2.)
3.)

17. Partner Insurance Information
My partner is currently covered by insurance: *
1.)
2.)
3.)

18. Authorization
Company Email:
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