Online 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 bold, red captions and asterisks (*) are required. Please complete all of these fields.

First Name * Middle Initial Last Name * Social Security Number *
Date of Birth * Height * Weight * Ethnicity * (Ethnic Group)
feet inches pounds
Address * City * State * Zip *
Home Phone * Mobile Phone Work Phone Email Address *
Occupation * Employer
Employer Address City State Zip

 

How many months have you been sexually active with your current partner without using contraception?  
 
How many months have you been attempting pregnancy?  
 
What's the reason for your consultation today?  

2. Pregnancy History

I have been pregnant:

1)
Date of Conception Time to Conceive Length of Pregnancy Is current partner the father?
years months months
Outcome Complications Sex Weight
pounds ounces
Infertility Treatment Other Complications or Details
2)
Date of Conception Time to Conceive Length of Pregnancy Is current partner the father?
years months months
Outcome Complications Sex Weight
pounds ounces
Infertility Treatment Other Complications or Details
3)
Date of Conception Time to Conceive Length of Pregnancy Is current partner the father?
years months months
Outcome Complications Sex Weight
pounds ounces
Infertility Treatment Other Complications or Details
4)
Date of Conception Time to Conceive Length of Pregnancy Is current partner the father?
years months months
Outcome Complications Sex Weight
pounds ounces
Infertility Treatment Other Complications or Details
5)
Date of Conception Time to Conceive Length of Pregnancy Is current partner the father?
years months months
Outcome Complications Sex Weight
pounds ounces
Infertility Treatment Other Complications or Details

3. Menstrual/Gynecological History

OB/GYN Phone
Address City State Zip
Date of last pap smear Date your last period began Age at your first period
Are your periods regular? Time from onset to onset Time your period lasts
days days
Do you bleed between periods? Do you have premenstrual symptoms?

Do you experience pelvic pain or cramps?

Frequency
Severity
Status
 
Location
Occurence
Triggers
Medications taken for menstrual discomfort

4. Contraceptive History

I have used contraceptives:

1)
Type Dates Used Reasons for Use:
to

Reasons for Discontinuation:
2)
Type Dates Used Reasons for Use:
to

Reasons for Discontinuation:
3)
Type Dates Used Reasons for Use:
to

Reasons for Discontinuation:
4)
Type Dates Used Reasons for Use:
to

Reasons for Discontinuation:
5)
Type Dates Used Reasons for Use:
to

Reasons for Discontinuation:

5. Sexual History

Fields with bold, red captions and asterisks (*) are required. Please complete all of these fields.

How many times a week do you have sexual intercourse? * How many times do you have intercourse around ovulation? *
Do you use lubricants for intercourse? * Do you douche before or after intercourse? *

Have you ever had unwanted sexual experiences or sexual problems? *


6. Medical History

Primary Care Provider Phone Practice Name
Address City State Zip

Do you have or have you had:

If you checked any of the above, please explain conditions, occurences, and treatments:


Please explain any serious or chronic illnesses or injuries not already described:



7. Medical Allergies

I am allergic to some medications:

Please list medications to which you are allergic and describe the specific allergic reactions which result.

Please explain any other known allergies including environmental allergens.

I am allergic to latex:

Please describe your reaction to latex:


8. Medications

Please complete the following, including listing all prescriptions, vitamins, nutritional supplements, and over-the-counter medications.

I take prescription medications:
I take vitamins or supplements:
1)
Medication or Supplement Dates Used
to
Dosage and Frequency Reason for Use
2)
Medication or Supplement Dates Used
to
Dosage and Frequency Reason for Use
3)
Medication or Supplement Dates Used
to
Dosage and Frequency Reason for Use
4)
Medication or Supplement Dates Used
to
Dosage and Frequency Reason for Use
5)
Medication or Supplement Dates Used
to
Dosage and Frequency Reason for Use

9. Surgical History/Previous Procedures

I have had at least one operation or procedure:

1)
Date Performed Hospital Physician
Condition Treatment or Procedure
2)
Date Performed Hospital Physician
Condition Treatment or Procedure
3)
Date Performed Hospital Physician
Condition Treatment or Procedure
4)
Date Performed Hospital Physician
Condition Treatment or Procedure

10. Social History

Tobacco Use (packs per day) Alcohol Use (drinks per day) Caffeine Use (drinks per day)
Marijuana Use Illicit Drug Use Dietary or Herbal Supplement Use
Television Use Electric Blanket Use Hot Tub or Sauna Use

Vigorous Exercise

1)
Type Hours per Week Reason for Exercise
2)
Type Hours per Week Reason for Exercise
3)
Type Hours per Week Reason for Exercise
4)
Type Hours per Week Reason for Exercise

11. Family History

Have you or anyone in your family had:

 

If you checked any of the above, please explain relation and conditions:



12. Partner History

I have a partner:
If Yes, complete all fields below:
First Name Middle Initial Last Name Social Security Number
Ethnicity Date of Birth Length of Relationship
years months
Height Weight
feet inches pounds
Address City State Zip
Home Phone Mobile Phone Work Phone Email Address
Occupation Employer
Employer Address City State Zip

13. Partner Social History

Tobacco Use (packs per day) Alcohol Use (drinks per day) Caffeine Use (drinks per day)



Marijuana Use Illicit Drug Use Dietary or Herbal Supplement Use



Television Use Electric Blanket Use Hot Tub or Sauna Use



Vigorous Exercise

1)
Type Hours per Week Reason for Exercise
2)
Type Hours per Week Reason for Exercise
3)
Type Hours per Week Reason for Exercise
4)
Type Hours per Week Reason for Exercise

Does your partner have or has your partner had:

If you checked any of the above, please explain conditions, occurences, and treatments:


If you checked any of the above, please list any related medications your partner is taking:


Please list any medications to which your partner is allergic:


Please explain any serious or chronic illnesses or injuries not already described:


Has your partner ever experienced problems with erection or ejaculation? Treatment?


Has your partner fathered a pregnancy in the past?


Has your partner's semen analysis ever been abnormal?


Has your partner seen a doctor for an infertility evaluation?


Has your partner or anyone in your partner's family had:

If you checked any of the above, please explain relation and conditions:



14. Fertility Testing History

Test

Values, Details, or Results

Basal Body Temperature
Urine Ovulation Predictor
Chlamydia/Gonorrhea Culture
Follicle-Stimulating Hormone (FSH)
Luteinizing Hormone (LH)
Prolactin
Thyroid Screening
Dehydroepiandrosterone (DHEA)
Testosterone
Estradiol
Progesterone
Mycoplasma Culture
Hysterosalpingogram (HSG)
Pelvic Ultrasound
Intravenous Pyelogram (IVP)
Laparoscopy
Hysteroscopy
Karyotype (Chromosome) Testing
Coagulation (Blood Clotting) Screening
Blood Type/Antibody Screening
Lupus Anticoagulant
Lupus Anticardiolipin Antibodies
Endometrial Biopsy
Urine Luteinizing Hormone (LH) Surge

Please explain any tests and results not already described:



15. Fertility Treatment History

Treatment

Dates Used

Dose, Details, or Results

Antibodies Injections to
Clomiphene (Clomid, Serophene, Milophene) to
Letrozole, Anastrazole to
hCG (Pregnyl, Profasi, Novarel, Ovidrel) to
Progesterone (Injections, Pills, Suppositories) to
Estrogen (Skin Patch, Pills, Suppositories) to
Dexamethasone to
GnRH Agonist (Synarel, Lupron) to
GnRH Antagonists (Cetrotide, Ganirelix) to
Intrauterine Insemination to
Insemination with Donor Sperm to
In Vitro Fertilization (IVF) to
IVF With Donor Egg to
Gonadotropins
(Follistim, Menopur, Bravelle Gonal F, Repronex)
to

Please explain any treatments and results not already described:



16. Insurance Information

I am currently covered by insurance:

1)
Insurance Company * Phone *
Address * City * State * Zip *
Policy Holder * Policy Number * Group/Account Number * Type of Plan *
2)
Insurance Company Phone
Address City State Zip
Policy Holder Policy Number Group/Account Number Type of Plan
3)
Insurance Company Phone
Address City State Zip
Policy Holder Policy Number Group/Account Number Type of Plan

17. Partner Insurance Information

My partner is currently covered by insurance:

1)
Insurance Company Phone
Address City State Zip
Policy Holder Policy Number Group Number Type of Plan
2)
Insurance Company Phone
Address City State Zip
Policy Holder Policy Number Group Number Type of Plan
3)
Insurance Company Phone
Address City State Zip
Policy Holder Policy Number Group Number Type of Plan

18. Authorization

It is frequently necessary for personnel at REACH to communicate lab results, instructions, information about treatement, and other protected health information with our patients. It is frequently not possible to speak personally with the patient to leave this information. In the event that our personnel are not able to speak with you directly, please let us know how we can communicate it to you.

Please indicate contact preferences below and provide phone numbers in the appropriate boxes:

Messages may be left on my voicemail at home:

Messages may be left on my mobile phone voicemail:

Messages may be left on my voicemail at work:

Messages may be sent to me via email:

Messages may be left with my partner:

My home answering device does not identify me by name, but it is appropriate to leave messages for me there:

Other persons are authorized to receive messages on my behalf:
    Name:       Number:

By checking any of the above boxes, I hereby release, discharge, and agree to hold harmless all parties to whom this consent is given from any liability that may arise from the release of information authorized above. I understand that I may revoke this consent in writing at any time. This consent is valid for two years from the date of signature unless otherwise revoked in writing. PLEASE CLICK ONE OF THE BUTTONS BELOW.

I hereby authorize REACH to file insurance and release all medical information necessary for the processing of insurance claims on my behalf. I am aware that even though REACH is contracted with my insurance company, I will be responsible at the time of service for any fees not covered by my current policy.

I DO NOT authorize REACH to file my insurance. I take full responsibility for all office visits and procedures on my behalf and my spouse when applicable. Any insurance claims or release of medical records for myself or my spouse to my insurance company will be allowed only at my request.

It is your responsibility to know and understand what type of coverage you have for infertility. We are happy to file claims on your behalf but we do not guarantee any type of payment from your insurance carrier.

Finalize this document by completing the electronic signature box below then click submit button.

Full Name: *
Email: *
Enter your initials: *

How it works: By entering your name and initals, you agree to accept the terms of the above document with an electronic signature.

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