Questionnaire

Please complete this online questionnaire as accurately as possible at least three days prior to your consultation. We look forward to your upcoming consultation.

You can also download a PDF of this questionnaire by clicking HERE and email a copy to info@laivfclinic.com or print and fax a copy to 626-744-3266

CLINICAL QUESTIONNAIRE

Step 1 of 7

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This field is for validation purposes and should be left unchanged.
Email
Patient's Name
First Last
Patient's Biological Gender
- Male
- Female
- Other
- Declined to Answer
Patient's Birth Date
MM slash DD slash YYYY
Patient's Marital Status
- Single
- Married
Partner's Name
First Last
Partner's Biological Gender
- Male
- Female
- Other
- Declined to Answer
Partner's Birth Date
MM slash DD slash YYYY
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Work Phone
Home Phone
Patient's Cell Phone
Partner's Cell Phone
Patient's Social Security Number
Partner's Social Security Number
Do you have medical insurance?
- Yes
- No
What type of medical insurance do you have?
- PPO
- HMO
- EPO
What is the name of your insurance?
INSURANCE CARD: Please take a picture of the front and back of your Insurance Card and upload by clicking the button below
Drop files here or

Max. file size: 5 MB.
Do you have a driver's license or picture ID?
- Yes
- No
DRIVER'S LICENSE: Please take a picture of the front of your Driver's License/ID Card and upload by clicking the button below
Drop files here or

Max. file size: 5 MB.
How were you referred to our center?
- Friend or Relative
- Internet Search
- Yelp
- Google
- Ob-Gyn / Physician
- Other
Referring Physician (Name and phone number):
Date of Consultation with Dr. Bayrak
MM slash DD slash YYYY

OBSTETRICAL HISTORY:
What is the name and contact information of your Obstetrician/Gynecologist?
How many years have you been trying to have a baby?
Please answer in Years
Please enter a number less than or equal to 50.
Have you ever been pregnant before?
- Yes
- No

Enter Pregnancy Information

You can add more rows by clicking (+) on the right of the row

Current (C) or Prior Partner (P)	Date	Weeks	Live Birth (Y/N)	Miscarriage (M) Abortion (A) Ectopic (E)	Fetal Heart (Y/N)	D&C (Y/N)	Vaginal (V) Cesarean (C)	Sex / Weight

Please Describe Complications

GYNECOLOGIC HISTORY:
When was the first day of your last period?
MM slash DD slash YYYY
Do you have regular periods?
- Yes
- No
Age at first period
Please enter a number less than or equal to 99.
Number of days of bleeding?
Please enter a number less than or equal to 99.
Number of days between the start of one period to the start of the next one?
Please enter a number less than or equal to 99.
Amount of bleeding:
- Light
- Medium
- Heavy
Do you have pain with menstruation?
- Yes
- No
Degree of pain:
- Mild
- Moderate
- Severe
Do you have pain with ovulation?
- Yes
- No
Do you experience pain with sexual intercourse?
- Yes
- No
Are you experiencing a vaginal discharge?
- Yes
- No
When was your last Pap smear and the result?
Have you ever had an abnormal Pap smear?
- Yes
- No
If yes, what follow up was needed?
If yes, what follow up was needed?
Have you ever had a mammogram?
- Yes
- No
If yes, what was the result and the date?

Have you ever had a sexually transmitted disease?

(i.e. Chlamydia, Gonorrhea, Syphilis, Herpes)

When?	What Type?

Have you ever had Pelvic Inflammatory Disease (PID)?
(i.e. Chlamydia, Gonorrhea, Syphilis, Herpes)
- Yes
- No
When?
Was it treated?
- Yes
- No
Do you experience milky or any discharge from your breasts?
- Yes
- No
Do you have uterine fibroids, ovarian cysts or endometriosis?
- Yes
- No
Have you ever used an IUD or any other form of contraception?
- Yes
- No
Please Describe (IUD or any other form of contraception)

PREVIOUS SURGERIES:
Have you ever had surgery?
- Yes
- No

Please Specify

You can add more rows by clicking the (+) icon on the right of the row

Procedure	Date	Indication	Outcome

MEDICAL CONDITIONS:
Do you have any of the following conditions?
Any Type Of Cancer
- Yes
- No
Comments
Anxiety or Panic disorder
- Yes
- No
Comments
Arthritis
- Yes
- No
Comments
Asthma
- Yes
- No
Comments
Attention Deficit Hyperactivity Disorder (ADHD or ADD)
- Yes
- No
Comments
Frequent Bladder Infection
- Yes
- No
Comments
Bleeding Tendency or Intestinal Bleeding
- Yes
- No
Comments
Clot Formation in Legs or Lung
- Yes
- No
Comments
Diabetes
- Yes
- No
Comments
Depression/Psychiatric Problems
- Yes
- No
Comments
Heart Disease/ High Blood Pressure
- Yes
- No
Comments
Hepatitis
- Yes
- No
Comments
High Blood Pressure
- Yes
- No
Comments
Lung Disease/ Pneumonia History
- Yes
- No
Comments
Kidney Disease/ Infection/ Stones
- Yes
- No
Comments
Migraine
- Yes
- No
Comments
Neurological or Psychiatric Disorders
- Yes
- No
Comments
Problems with Anesthesia
- Yes
- No
Comments
Rheumatic Fever/ Rheumatoid Arthritis
- Yes
- No
Comments
Systemic Lupus Erythematosus
- Yes
- No
Stomach Problems/ Gastritis/ Acid Reflux
- Yes
- No
Comments
Thyroid Disease
- Yes
- No
Comments
Tuberculosis
- Yes
- No
Comments
Varicose Veins
- Yes
- No
Comments
Other Medical Condition

DRUG ALLERGIES:
Are you allergic to any medications that you know of?
- Yes
- No

Please Specify

You can add more rows by clicking the (+) icon on the right of the row

Medication	Reaction

CURRENT MEDICATIONS:
Are you currently taking any medications or supplements?
- Yes
- No

Please Specify

You can add more rows by clicking the (+) icon on the right of the row

Medication	Dose	Frequency

FAMILY HISTORY:
Is there a history of any of the following conditions in the family?
Any Type of Cancer?
- Yes
- No
Comments
Birth Defects or Down's Syndrome?
- Yes
- No
Comments
Blood Clots in Legs or Lung
- Yes
- No
Comments
Diabetes or Insulin Resistance
- Yes
- No
Comments
Early Menopause or Ovarian Failure
- Yes
- No
Comments
Heart Disease
- Yes
- No
Comments
High Blood Pressure
- Yes
- No
Comments
Infertility/ Polycystic Ovary Syndrome
- Yes
- No
Comments
Systemic Lupus Erythematosus (SLE)
- Yes
- No
Comments
Twins or Triplets
- Yes
- No
Comments
Ovarian or Uterine Cancer
- Yes
- No
Comments
Polycystic Ovary Syndrome (PCOS)
- Yes
- No
Comments
Twins or Triplets
- Yes
- No
Comments
Recurrent Miscarriages
- Yes
- No
Comments
Rheumatoid Arthritis or Lupus
- Yes
- No
Comments
Thyroid Disease
- Yes
- No
Comments
Any Medical Disorders/ Other Issues
SOCIAL HISTORY:
Occupation:
Weight:
Height
Do you use tobacco?
- Yes
- No
#Packs/day
Do you use alcohol?
- Yes
- No
#Drinks/wk
Have you ever used drugs?
- Yes
- No
How long have you been together with your current partner?
Have you had problems conceiving in a previous relationship?
- Yes
- No
- N/A
How frequently do you have intercourse?
Do you have to use a lubricant?
- Yes
- No
BACKGROUND INFORMATION:
Please check all that apply
- Ashkenazi Jewish
- Caucasian (Non-Hispanic)
- Hispanic
- African American
- Asian American
- Mixed/ Other
If "Mixed" or "Other" - Please specify
COMMENTS:
Please describe the nature of your problem:

PARTNER HISTORY:
Occupation:
Do you have any medical problems?
- Yes
- No
Please Specify
Have you ever had any surgeries?
- Yes
- No
Please Specify
Any family history of any major illnesses?
- Yes
- No
Please Specify
Have you initiated any pregnancies in the past?
- Yes
- No
Number of Pregnancies
Number with current partner?
When was the most recent pregnancy?
Have you been evaluated by a Urologist?
If applicable /male partner
- Yes
- No
Diagnosis:
Have you ever had a semen analysis?
If applicable/male partner
- Yes
- No
Please Specify:
Volume (ml or cc) / Count (million/ml) / Motility (% moving sperm) / Morphology (% normal forms - Kruger's or WHO Criteria?)
Have you ever had sperm DNA testing?
Please Specify - If applicable/male partner: Sperm DNA fragmentation index (DFI):% / High Density Stainability (HDS): %
Are you allergic to any medications?
- Yes
- No

Please Specify

Medication:	Reaction

Are you taking any medications?
- Yes
- No

Please Specify

Medication:	Dose	Reaction

Do you use Tobacco?
- Yes
- No
#Packs/day
Do you use Alcohol?
- Yes
- No
#Drinks/wk
Have you ever used drugs?
- Yes
- No
Do you use a hot tub or wear tight underwear?
- Yes
- No
#Times/wk
Tests or Procedures
Have you had any of the following tests or procedures? For male partner only /
Male Blood Tests
FSH
- Yes
- No
FSH - Please specify
Date Result Comment
LH
- Yes
- No
LH - Please specify
Date Result Comment
Testosterone
- Yes
- No
Testosterone - Please specify
Date Result Comment
TSH
- Yes
- No
TSH - Please specify
Date Result Comment
Prolactin
- Yes
- No
Prolactin - Please specify
Date Result Comment
DQ Alpha or HLA
- Yes
- No
DQ Alpha or HLA - Please Specify
Date Result Comment
Semen Culture
- Yes
- No
Semen Culture - Please Specify
Date Result Comment
Surgery
Vasectomy
- Yes
- No
Vasectomy - Please Specify
Date Result Comment
Vasectomy Reversal
- Yes
- No
Vasectomy Reversal - Please Specify
Date Result Comment
Testicular Biopsy
- Yes
- No
Testicular Biopsy - Please Specify
Date Result Comment
Varicocele Surgery
- Yes
- No
Varicocele Surgery - Please Specify
Date Result Comment
Hernia Repair
- Yes
- No
Hernia Repair - Please Specify
Date Result Comment
Undescended Testicle
- Yes
- No
Undescended Testicle - Please Specify
Date Result Comment
Removal Testicle (s)
- Yes
- No
Removal of Testicle (s) - Please Specify
Date Result Comment
Tesa or Mesa
- Yes
- No
TESE or MESA - Please Specify
Date Result Comment

Other - Please Specify

Date	Result	Comment

PREVIOUS INFERTILITY EVALUATION:
Have you ever had any of the following tests or procedures? Please enter all that apply. For Female Patient only
Female Blood Tests
FSH (Cycle day3)
- Yes
- No
FSH (Cycle day 3) - Please Specify
Date Result
Estradiol (Cycle Day3)
- Yes
- No
Estradiol (Cycle day 3) - Please Specify
Date Result
Anti - Mullerian Hormone (AMH)
- Yes
- No
Anti-Mullerian Hormone (AMH) - Please Specify
Date Result
Inhibin B Level
- Yes
- No
Inhibin B level - Please Specify
Date Result
LH (Cycle day 3)
- Yes
- No
LH (Cycle day 3) - Please Specify
Date Result
Progesterone (7 days after ovulation)
- Yes
- No
Progesterone (7 days after ovulation) - Please Specify
Date Result
TSH
- Yes
- No
TSH - Please Specify
Date Result
Proclatin
- Yes
- No
Prolactin - Please Specify
Date Result
DHEAS
- Yes
- No
DHEAS - Please Specify
Date Result
Testesterone
- Yes
- No
Testosterone - Please Specify
Date Result
17 Hydroxy-Progesterone
- Yes
- No
17 Hydroxy-Progesterone - Please Specify
Date Result
Blood type and Rh status
- Yes
- No
Blood type and Rh status - Please Specify
Date Result
Rubella / Varicella Titers
- Yes
- No
Rubella/Varicella Titers - Please Specify
Date Result
HIV
- Yes
- No
HIV - Please Specify
Date Result
Hepatitis B surface antigen
- Yes
- No
Hepatitis B surface antigen - Please Specify
Date Result
Hepatitis C antibody
- Yes
- No
Hepatitis C antibody - Please Specify
Date Result
RPR / VDRL (Syphilis)
- Yes
- No
RPR/ VDRL (Syphilis) - Please Specify
Date Result
Blood tests (Immunologic)
Anti Nuclear Antibodies (ANA)
- Yes
- No
Anti-Nuclear Antibodies (ANA) - Please Specify
Date Result
Anti-Phospholipid Antibodies (APA)
- Yes
- No
Anti-Phospholipid Antibodies (APA) - Please Specify
Date Result
Anti-Paternal Leukocyte Antibodies (APLA)
- Yes
- No
Anti-Paternal Leukocyte Antibodies (APLA) - Please Specify
Date Result
Natural Killer (NK) cell assay
- Yes
- No
Natural Killer (NK) cell assay - Please Specify
Date Result
Immunophenotype
- Yes
- No
Immunophenotype - Please Specify
Date Result
DQ Alpha or HLA testing
- Yes
- No
DQ Alpha or HLA testing - Please Specify
Date Result
Anti-Thyroglobulin Antibodies (ATA)
- Yes
- No
Anti-Thyroglobulin Antibodies (ATA) - Please Specify
Date Result
Anti-Microsomal Antibodies (AMA, TPO)
- Yes
- No
Anti-Microsomal Antibodies (AMA, TPO) - Please Specify
Date Result
Anti-Sperm Antibodies
- Yes
- No
Anti-Sperm Antibodies - Please Specify
Date Result
IgA level
- Yes
- No
IgA level - Please Specify
Date Result
Thrombophilia work up (clotting disorder)
- Yes
- No
Thrombophilia work up (clotting disorders) - Please Specify
Date Result
Cervical/Vaginal Cultures
Chlamydia / Gonorrhea
- Yes
- No
Chlamydia/Gonorrhea - Please Specify
Date Result
Ureaplasma / Mycoplasma
- Yes
- No
Ureaplasma/Mycoplasma - Please Specify
Date Result
General Assessment
Gynecological exam
- Yes
- No
Gynecological exam - Please Specify
Date Result
Mammogram
- Yes
- No
Mammogram - Please Specify
Date Result
Physical exam
- Yes
- No
Physical exam - Please Specify
Date Result
Basal Body Temperature Chart (BBT)
- Yes
- No
Basal Body Temperature Chart (BBT) - Please Specify
Date Result
Ovulation Predictors Kits (OPK or LH kit)
- Yes
- No
Ovulation Predictor Kits (OPK or LH kit) - Please Specify
Date Result
Endometrial biopsy
- Yes
- No
Endometrial biopsy - Please Specify
Date Result
Pelvic exam
- Yes
- No
Pelvic exam - Please Specify
Date Result
Vaginal ultrasound
- Yes
- No
Vaginal ultrasound - Please Specify
Date Result
Hysterosalpingogram (HSG) (Dye test)
- Yes
- No
Hysterosalpingogram (HSG) (Dye Test) - Please Specify
Date Result
Fluis ultrasound (Hydrosonography)
- Yes
- No
Fluid ultrasound (Hydrosonography) - Please Specify
Date Result
Hysteroscopy (Camera to look inside uterus)
- Yes
- No
Hysteroscopy (Camera to look inside uterus) - Please Specify
Date Result
Laparoscopy (Camera to look inside abdomen)
- Yes
- No
Laparoscopy (Camera to look inside abdomen) - Please Specify
Date Result
Laparotomy (Open abdominal surgery)
- Yes
- No
Laparotomy (Open abdominal surgery) - Please Specify
Date Result

Other (if any) - Please Specify

Date	Result

PREVIOUS INFERTILITY TREATMENT
Have you ever used any of the following medications or treatments?
Medication
Clomiphene Citrate (Oral) or Femara (Oral)
- Yes
- No
Clomiphene Citrate (Oral) or Femara (Oral) - Please Specify
Date Dose #Cycles Comment
Gonal F, Follistim, Repronex, Menopur, Bravelle, Luveris (Injectible Medications)
- Yes
- No
Gonal F, Follistim, Repronex, Menopur, Bravelle, Luveris (Injectible Medications) - Please Specify
Date Dose #Cycles Comment
HCG (Novarel, Pregnyl, Ovidrel) - Please Specify
- Yes
- No
HCG (Novarel, Pregnyl, Ovidrel)
Date Dose #Cycles Comment
Progesterone
- Yes
- No
Progesterone - Please Specify
Date Dose #Cycles Comment
Heparin or Lovenox or Apsirin
- Yes
- No
Heparin or Lovenox - Please Specify
Date Dose #Cycles Comment
Prednisilone (Medrol)
- Yes
- No
Prednisilone (Medrol) - Please Specify
Date Dose #Cycles Comment
Prednisone
- Yes
- No
Prednisone - Please Specify
Date Dose #Cycles Comment
Dexamethasone
- Yes
- No
Dexamethasone - Please Specify
Date Dose #Cycles Comment
Intravenous Immunoglobulin (IVIG) or Intralipid
- Yes
- No
Intravenous Immunoglobulin (IVIG) or Intralipid - Please Specify
Date Dose #Cycles Comment
Leukocyte Immunization Therapy (LIT)
- Yes
- No
Leukocyte Immunization Therapy (LIT) - Please Specify
Date Dose #Cycles Comment
Treatment
Timed Intercourse
- Yes
- No
Timed Intercourse - Please Specify
Date Dose #Cycles Comment
Intrauterine Insemination (IUI)
- Yes
- No
Intrauterine Insemination (IUI) - Please Specify
Date Dose #Cycles Comment
In Vitro Fertilization (IVF)
- Yes
- No

In Vitro Fertilization (IVF) - Please Specify

You can add more rows by clicking the (+) icon on the right of the row

Date	Dose	#Cycles	Comment

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- Yes
- No
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- Yes
- No
Emergency Contact Person's Full Name
First Last
Emergency Contact Person's Phone Number
I confirm that all the information I have entered is correct and I have read, understand that LAIVF CLINIC will contact me using the information provided.*
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Questionnaire

Questionnaire

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CLINICAL QUESTIONNAIRE

Step 1 of 7

OBSTETRICAL HISTORY:

GYNECOLOGIC HISTORY:

PREVIOUS SURGERIES:

MEDICAL CONDITIONS:

DRUG ALLERGIES:

CURRENT MEDICATIONS:

FAMILY HISTORY:

SOCIAL HISTORY:

BACKGROUND INFORMATION:

COMMENTS:

PARTNER HISTORY:

Tests or Procedures

Male Blood Tests

Surgery

PREVIOUS INFERTILITY EVALUATION:

Female Blood Tests

Blood tests (Immunologic)

Cervical/Vaginal Cultures

General Assessment

PREVIOUS INFERTILITY TREATMENT

Medication

Treatment

REQUEST CONSULTATION

SHARE

LATEST BLOG

Navigating Work While Undergoing Fertility Treatments

Breast Cancer and Egg Freezing

The Connection Between Breast Cancer and Fertility

Search

CLINICAL QUESTIONNAIRE

Step 1 of 7

OBSTETRICAL HISTORY:

GYNECOLOGIC HISTORY:

PREVIOUS SURGERIES:

MEDICAL CONDITIONS:

DRUG ALLERGIES:

CURRENT MEDICATIONS:

FAMILY HISTORY:

SOCIAL HISTORY:

BACKGROUND INFORMATION:

COMMENTS:

PARTNER HISTORY:

Tests or Procedures

Male Blood Tests

Surgery

PREVIOUS INFERTILITY EVALUATION:

Female Blood Tests

Blood tests (Immunologic)

Cervical/Vaginal Cultures

General Assessment

PREVIOUS INFERTILITY TREATMENT

Medication

Treatment

REQUEST CONSULTATION

SHARE

LATEST BLOG

Navigating Work While Undergoing Fertility Treatments

Breast Cancer and Egg Freezing

The Connection Between Breast Cancer and Fertility

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