Your Name (required)
Date of Birth (required)
Your age (required)
City, State, Zip Code (required)
Phone Number (required) (best number to call)
Your Email (required)
Are You Married or Have a Partner (required)
How long have you been having regular unprotected intercourse?(required)
How long have you been trying to actively get pregnant? (required)
How long have you been trying to get pregnant with a Doctor's help? (required)
Was the Doctor a: □ General Gynecologist □ Reproductive Endocrinology & Infertility Specialist (required)
Approximately how many times a week do you have intercourse on average? (required)
Does either you or your partner smoke? (required)
How much (cig/day)? (required)
Does either you or your partner drink alcohol? (required)
How much? (required)
Ethnic background (required)
Do you have allergies? (If so, please list below and include allergies to medications if applicable:
Menstrual periods occur every (days)
Are they regular? Are They Regular (Please type Yes or No)
Duration of bleeding (days)
Amount of bleeding
Are your periods painful?
Do you have endometriosis? YES NO? Do you have any medical problems? □ YES □ NO If yes, explain:
What other information should we know about your case?
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