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

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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I acknowledge that I received a copy of the Notice of Privacy Practices for LA IVF as required by The Federal Health Insurance Portability and Accountability Act. Please check one:
- 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

What Is Preimplantation Genetic Testing (PGT) & Why It Matters for IVF?

How Long Does IVF Take? Understanding the Timeline of Treatment

How to Know When It’s Time to See a Fertility Specialist

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

What Is Preimplantation Genetic Testing (PGT) & Why It Matters for IVF?

How Long Does IVF Take? Understanding the Timeline of Treatment

How to Know When It’s Time to See a Fertility Specialist

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