Female Medical Form

Female Medical History Form

Preferred Name:    D.O.B.:    Age:    Today’s Date:

Legal Name (if different from preferred name):

Occupation:    Highest Education:    Ethnic Background:

Ht:    Wt:    Partner’s Name (if applicable):    D.O.B.:

Is the primary reason for your visit:

Infertility    Recurrent Pregnancy Loss    Endocrine Disorder    Fertility Preservation    Other:

Please tell us about some of your goals/expectations for your visit today:

Gynecological History:

Age of first period:    Start dates of last 3 periods: , ,

How often do you get a period? Never Regular, every to days Irregular, every to days

Usual duration of bleeding: days

Amount of flow: Light Moderate Heavy

Is cramping: Minimal Moderate Severe No cramping

Do you experience bleeding between periods? Yes No

Do you have symptoms at the time of ovulation (i.e., pain)? Yes No

Do you have a history of pelvic pain? Yes No

Do you have a history of endometriosis? Yes No

Have you ever had a tubal ligation? Yes No If yes, when

Please list any other gynecological surgeries (date, type, outcome/complications):

Dates of last PAP    Breast Exam    Mammogram

Sexual History:

Frequency of sexual intercourse: times per week    Do you use lubricants? Yes No Type:

Does your partner ejaculate in your vagina during intercourse? Yes No

Is intercourse painful to you? Yes No

Is intercourse painful to your partner? Yes No

Do you have a history of genital herpes? Yes No

Have you ever been treated for:

Syphilis Yes Date: No    Chlamydia Yes Date: No

Gonorrhea Yes Date: No    Genital warts Yes Date: No

Please let the doctor know if you: currently are not sexually active never had sexual intercourse have been sexually abused

Contraceptive History:

Have you taken birth control pills? Yes No

If yes, how many years did you take birth control pills?    Date birth control was last taken:

Were menses regular before birth control pills? Yes No

Were menses regular after stopping birth control pills? Yes No

How long after stopping birth control pills did menses start?

Any previous use of IUD (intrauterine device)? Yes No

If yes, # of years taken:    Date of removal:    Reason:

Please mark any previous contraception used: diaphragm condom foam rhythm female sterilization male sterilization none

Obstetrical History:

Have you been pregnant before? Yes No If yes, please record all pregnancies in the table below.

Patient Medical History:

Have you ever been involved in psychotherapy or counseling? Yes No If yes, please indicate why, with whom, and any other pertinent information:

Patient Surgical History:

Please list any other surgeries you have had (type of surgery and year):

Medications:

Please list any prescription and over the counter medications you are taking now or have taken in the past:

Currently taking:

Previously taken:

Do you have any history of therapeutic x-ray treatment or anti-cancer drugs? Yes No If yes, what and when:

Allergies:

Do you have any allergies (medications, food, latex, iodine, contrast dye)? Yes No If yes, please indicate allergies and reactions experienced:

Occupational/Leisure History:

Are you exposed to chemicals or x-rays in work or hobby? No Yes dates/comments:

Do you consume/use: Yes / No Amount per day/week:

Caffeine Yes No

Smoking Yes No

Alcohol Yes No

Marijuana Yes No

Nutritional Supplements, Herbs, etc. Yes No

Drugs Yes No

Please describe any recreational/sport activities (frequency, length of time, etc.):

Family History:

Father’s age, if alive: If deceased, cause of death:

Medical problems:

Mother’s age, if alive: If deceased, cause of death:

Medical problems:

Age at Menopause:

Did your mother take DES or any other medications while pregnant with you? Yes medication No Unknown

Sister(s) age: Medical problems:

Brother(s) age: Medical problems:

Is there a family history of:

Review of Systems:

Please fill in a review of any current or recent symptoms YOU have experienced:

Pre-Conceptual Health Screening:

Previous Infertility Testing:

Length of time currently attempting pregnancy: Years Months

Length of time not using contraceptives: Years Months

Have you previously had a reproductive endocrinology and infertility evaluation? Yes No

Do you have an infertility diagnosis? Yes No If yes, please note diagnosis:

Previous Infertility Treatment (Continued):

Have you ever had treatment with Clomiphene (Clomid, Serophene)? Yes No

If yes:

Cycles without Intrauterine Insemination (IUI)? Yes #Cycles & Dates No

Cycles with Intrauterine Insemination (IUI)? Yes #Cycles & Dates No

Did the clomid cycle(s) result in pregnancy? Yes #Cycles & Dates No

Have you ever had treatment with Gonadotropins (Follistim, Gonal-F, and Menopur)? Yes No

If yes:

Cycles without Intrauterine Insemination (IUI)? Yes #Cycles & Dates No

Cycles with Intrauterine Insemination (IUI)? Yes #Cycles & Dates No

Did the gonadotropin cycle(s) result in pregnancy? Yes #Cycles & Dates No

Have you ever had treatment with IVF or other Reproductive Technologies (GIFT, ZIFT)? Yes No

Other comments on infertility treatments:

Please include any other information which you believe may be pertinent to your fertility:

Patient Responsibilities/Consents

Patient Name:

Patient D.O.B.:

Financial Responsibility:

Patients are required to pay any non-covered services on the day of service in full. Cash, check, Visa, MasterCard, and American Express are all acceptable forms of payment.

PATIENTS WITH INSURANCE COVERAGE

We will gladly discuss your proposed treatment and answer any questions relating to your insurance. We must, however, emphasize that as medical care providers, our relationship is with you, not your insurance company. It is your responsibility to be aware of your insurance coverage. While Main Line Fertility is responsible for timely filing of your insurance claims, all charges are your responsibility from the date services are rendered and YOU ARE RESPONSIBLE FOR RESOLVING ANY PROBLEMS WITH YOUR INSURANCE COMPANY.

Portions of the bill that may not be paid by the insurance company are to be paid by the patient, i.e. COINSURANCE, DEDUCTIBLES OR BALANCES FOR NON-COVERED SERVICES. If your insurance company has not paid your claim, you will be required to pay services rendered and any insurance benefit later received will be credited and you will be refunded.

Furthermore, it is the patient’s responsibility to obtain any referrals or authorizations required by your insurance plan(s) prior to the appointment from either the Primary Care Physician or the referral/authorization hotline determined by your insurance policy. If the appropriate referral or authorization is not obtained, you will be responsible for payment of services in full if the insurance company refuses payment on any submitted claim.

PAYMENT OF BALANCE

If your insurance company sends you a check for services rendered by Main Line Fertility and Reproductive Medicine, LTD or Main Line Fertility Center, Inc., you agree to endorse and forward that check to the address below. You also agree to be financially responsible and to promptly pay any balance for professional services not covered or paid in full by your insurance company.

MEDICARE AND MEDICAID

If you have Medicare or Medicaid as a primary or secondary insurance, please be aware that we are a non-par opt-out provider. Therefore, if you choose to be seen by our physicians, you will have to pay the full amount of charges for your care on the date of service.

OUT OF NETWORK COVERAGE

If our facility or physicians are out of network with your insurance plan and you choose to be seen for medical testing/treatment, you are accepting full responsibility of any patient balance which may accumulate as a result and understand that this is not appealable thru your insurance carrier. Furthermore, if you are referred by our physicians or staff to an outside facility for lab work or other testing/treatment, it is your responsibility to verify if the facility participates with your insurance carrier and any and all fees that result from said testing are the patient responsibility and are not appealable thru your insurance carrier.

ADDITIONAL TERMS

Checks returned by your bank are subject to a $50 processing charge. Accounts greater than 60 days past due will be subject to a finance charge at the rate of 1.5% per month. If your account is referred for collection, you will be responsible for the outstanding balance, collection costs, court costs, and attorney’s fees. Furthermore, you will not be permitted to schedule further appointments until all collection costs are paid in full.

AUTHORIZATION TO RELEASE INFORMATION

You also authorize the release of any information pertinent to your case to any insurance company, adjuster or attorney involved in your case.

I have read and understand the financial policy of the office and understand that a photocopy of this assignment shall be considered as effective and valid as the original.

Patient Initials:

Authorization to leave voicemail regarding protected health information:

By initialing below, I authorize the practice to leave my protected health information (including but not limited to results, prescriptions and appointments) on my answering machine or voicemail at phone #

Patient Initials:

HIPAA - Notice of Privacy Practices:

I have reviewed and/or received the HIPAA Notice of Privacy Practices. (Copy is available in office or www.mainlinefertility.com.)

Patient Initials:

Authorization to Disclose Protected Health Information

I hereby authorize the disclosure of my protected health information (including HIV/AIDS related information, if any) to the person(s) designated below.

Name:    Relationship:

Name:    Relationship:

If box is checked, I do not authorize my protected health information to be released to persons other than myself.

Patient Initials:

Use of E-Mail:

Risk of Using Email:

Transmitting patient information by E-mail has a number of risks that patients should consider before using E-mail. These include, but are not limited to, the following risks:

a. It is possible that the confidentiality of such communications may be breached by a third party.

b. E-mail can be circulated, forwarded, stored electronically and on paper, and broadcast to unintended recipients.

c. E-mail senders can easily misaddress an E-mail.

d. E-mail is easier to falsify than handwritten or signed documents.

e. Backup copies of E-mail may exist even after the sender or the recipient has deleted his or her copy.

f. Employers and on-line services have a right to inspect E-mail transmitted through their systems.

g. E-mail can be intercepted, altered, forwarded, or used without authorization or detection.

h. E-mail can be used to introduce viruses into computer systems.

i. The server could go down and E-mail would not be received until the server is back on-line.

j. Email can be used as evidence in court.

Conditions for the Use of E-mail:

Main Line Fertility cannot guarantee but will use reasonable means to maintain security and confidentiality of E-mail information sent and received. Main Line Fertility and its employees, owners, or agents must acknowledge and consent to the following conditions:

a. E-mail is not appropriate for urgent or emergency situations. Main Line Fertility cannot guarantee that any particular E-mail will be read and responded to within any particular period of time.

b. Emails to or from the patient concerning treatment may be printed in full and made part of patient’s medical record or placed in any electronic file. Because they are part of the medical record, authorized individuals will have access to the medical record/email.

c. Main Line Fertility will not forward patient identifiable E-mails outside of Main Line Fertility without the patient’s prior written consent, except as authorized or required by law.

d. The patient should not use E-mail for communication regarding sensitive medical information, such as information regarding sexually transmitted diseases, AIDS/HIV, mental health, or substance abuse. Main Line Fertility is not responsible for breaches of confidentiality caused by the patient or any third party.

e. It is the patient’s responsibility to follow up and/or schedule an appointment if warranted.

f. This consent will remain in effect until terminated in writing by either the patient or Main Line Fertility.

g. In the event that the patient does not comply with the conditions herein, Main Line Fertility may terminate patient’s privilege to communicate by E-mail with Main Line Fertility.

Instructions: To communicate by E-mail, the patient shall:

a. Avoid use of his/her employer’s computer.

b. Put the patient’s name in the body of the E-mail.

c. Key in the topic (e.g., medical questions, billing question) in the subject line.

d. Inform Main Line Fertility of changes in his/her E-mail address.

e. Acknowledge any E-mail received from Main Line Fertility.

f. Take precautions to preserve the confidentiality of E-mail.

g. Protect his/her password or other means to E-mail.

Patient Acknowledgement and Agreement:

I acknowledge that I have read and fully understand this consent form. I understand the risks associated with the communication of E-mail and consents to the condition and instructions outlined, as well as any other instructions that Main Line Fertility may impose to communicate with patient by E-mail. If I have any questions, I may inquire with Main Line Fertility.

I, for myself, my heirs, executors, administrators and assigns, fully and forever release and discharge Main Line Fertility and its affiliates, shareholders, officers, directors, physicians, agents and employees, from and against any and all losses, claims, and liabilities arising out of or connected with the use of such E-mail.

Patient Initials:

Fertility Medication Consent:

I hereby consent to treatment with fertility medication as part of my treatment protocol by Main Line Fertility. The probability of pregnancy, given the specific characteristics of my case, have been explained to me. I understand there are other possible treatment options, including no treatment. I understand that if pregnancy is established, there is a risk of fetal malformation which is thought to be similar to spontaneously conceived pregnancies and am aware of the availability of tests to detect some, but not all fetal malformations during pregnancy. I am aware that multiple pregnancies and tubal/ectopic pregnancies and ovarian hyperstimulation syndrome can result from fertility medications. If conception occurs, there is a risk of pregnancy complications including, but not limited to: gestational diabetes, pre-eclampsia, bleeding, blood clot/stroke, even death. The risk of pregnancy complications is believed to be slightly higher in women requiring fertility treatment as compared to women who do not require any assistance to conceive.

I acknowledge that I have been given this information and have the opportunity to discuss with my physician and/or clinical staff all other questions and concerns.

Patient Initials:

Purchasing of Medication through Office:

Main Line Fertility is able to provide limited medications to be purchased in office at discounted price if they are not covered by your insurance. Once purchased, these medications are NOT returnable.

I understand that if I purchase any medication through Main Line Fertility the medication cannot be returned to the office and there are NO REFUNDS once purchased.

Patient Initials:

Zika Virus:

The Zika Virus is spread mostly by the bite of an infected Aedes species mosquito (Ae. aegypti and Ae. albopictus). These mosquitoes bite during the day and night. Many people infected with Zika virus won’t have symptoms or will only have mild symptoms. The most common symptoms of Zika are: Fever, rash, joint pain, red eyes, muscle pain and/or headache. Symptoms can last for several days to a week. People usually don’t get sick enough to go to the hospital, and they very rarely die of Zika.

• Zika can be passed from a pregnant woman to her fetus. Infection during pregnancy can cause certain birth defects.

• There is no vaccine or medicine for Zika.

• Local mosquito-borne Zika virus transmission has been reported in the continental United States

Per the Center for Disease Control (CDC) women with possible Zika virus exposure are recommended to wait to get pregnant until at least 8 weeks after symptom onset (if symptomatic) or last possible Zika virus exposure or travel to possible Zika infested area (if asymptomatic).

The CDC now recommends that all men with possible Zika virus exposure who are considering attempting pregnancy with their partner wait to get pregnant until at least 6 months after symptom onset (if symptomatic) or last possible Zika virus exposure (if asymptomatic).

The CDC recommends that if you are attempting pregnancy you check the CDC website for areas with Zika risk, talk to your doctor or other healthcare provider before traveling to areas with Zika risk, taking steps to plan for travel, and consider avoiding nonessential travel to areas with a CDC Zika travel notice.

There are still many unknowns about the Zika virus and its transmission. As updates become available Main Line Fertility will pass along such information and recommendations.

I have read this information, have had the opportunity to ask questions, have decided to accept the above risks known and unknown, and wish to proceed with fertility treatment to attempt pregnancy.

Patient Initials:

I am signing this form voluntarily and confirm that I have read and understand all consents included in this document. I understand that I have the right to a signed copy of this form if I request one.