Coastal Fertility New Patient Information

Welcome to Coastal Fertility Specialists! We are are looking forward to meeting you and want to thank you for choosing Coastal Fertility Specialists. We have a dedicated team of medical professionals focused on providing the absolute best medical care possible. We are not perfect but it’s not for a lack of trying. Please let us know how we are doing along the way.
 
During your new patient visit our goal is to provide you with the information you need to understand what’s is causing your reproductive problems and your options for treatment. The first step is for us to better understand your history and symptoms. This site is designed to allow you to enter your medical information securely online so it can be transmitted directly to our new patient coordinators. The information you enter will then be available to your physician and nurse during your upcoming new patient visit.
 
All of the information you enter is transmitted securely to Coastal Fertility Specialists through data encryption. If you are uncomfortable entering this information online that’s not a problem. We have a PDF of the forms on our website you can print and fax to us if you prefer. Those forms can be found at www.coastalnewpatient.com.
 
Thanks for taking the time to complete the information below. The fields with an * are required. Once the form is complete please press the submit button at the bottom.
Questions below pertain to patient demographics:


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May we contact you via email?
Have you or your partner been here before?




Are we able to contact you at work?
How did you hear about our practice?
Questions below pertain to the patient's closest living relative:
Questions below pertain to the partner of the patient:

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Questions below pertain to patient's primary insurance coverage:
Is your partner covered?
Questons below pertain to partner's insurance coverage:
Is your partner covered?
Please review and consent to agreement below:

Please print name below agreement:
I hereby make assignment of all surgical, medical and major medical insurance benefits to John A. Schnorr, MD, Dr. Cook and Michael J. Slowey, MD , and to release any medical information necessary to execute an assignment of benefits. I understand that regardless of any insurance coverage I might have, i am personally responsible for all charges to this account. I further agree in the event of non-payment to bear the cost of collection and/or court costs and reasonable legal fees should this be requested. *
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Partner's Signature:
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General Information

Are you having difficulty getting pregnant?


Are you having problems with miscarriages?

Obstetric History

Have you been pregnant in the past?
Please list year of pregnancy and pregnancy outcome: 
 YearMiscarriage/AbortionVaginal DeliveryCesarean SectionEctopicWeeks AlongComplications
1.
2.
3.
4.
5.

Gynecologic History

Do you have monthly menstrual cycles?
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Do you have pain with periods?
Do you have any problems with intercourse?
Do you have pain with intercourse?

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Was your last PAP smear normal?

Any history of abnormal PAP smears?

Have you ever had a sexually transmitted disease or pelvic infection?

Have you ever been told that you have endometriosis?
Have you ever been told that you have fibroids?

Fertility History

Have you had bloodwork performed to assess your infertility?

Have you had a hysterosalpingogram (X-ray test with dye) to assess your uterus and fallopian tubes?

If yes, was it normal?

Has your husband had a sperm test?

If yes, was the sperm count normal?
Have you undergone any fertility treatment?
If you answered yes to having undergone any fertility treatment, please answer the following:




Have you used clomid or femara (letrozole)?








Have you undergone any IUI treatments?








If yes, have you undergone treatment with injectable medications?




Have you undergone IVF?








Medical History

Are you being treated for any medical problems? (Examples include high blood pressure, diabetes, autoimmune problems, blood clotting disorders)




Are you taking any medications at this time?




Do you have any allergies to medications?




Have you had any surgery in your lifetime?




If yes, please list all surgeries (both gynecologic and non-gynecologic):
 YearSurgeryFindingsComplications
1.
2.
3.
4.
5.

Family and Social History

Do you smoke cigarettes or use tobacco?






Do you drink alcohol?



Do you use any illicit drugs?

Do you drink caffeinated beverages?






Please list any medical conditions in family members:




Do you have history of breast cancer or gynecologic cancer in your family?
Do you have history of blood clotting in your family?
Does anyone in your family have fertility issues?

Partner: General Information

Do you have any children in the current or past relationships?

Have you ever had a semen analysis performed?
Have you had any issue with infertility in previous relationships?

If yes, was the semen analysis normal?
Do you have any difficulty with intercourse or maintaining an erection?

Have you ever had any sexually transmitted diseases?

Have you ever had surgery or trauma to the genitals?

Have you ever been seen by a urologist?


Have you ever taken medications to improve fertility?

Are you being treated for any medical issues?

Are you currently on any medications?

Do you have any allergies to medications?

Are you taking any supplements or testosterone?

Have you had surgery in your lifetime?




If yes, please list all surgeries:
 YearSurgeryFindingsComplications
1.
2.
3.
4.
5.

Please list any medical conditions in family members:




Do you smoke cigarettes or use tobacco?






Do you drink alcohol?



Do you use any illicit drugs?

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