Center for Infertility & Reproductive Surgery – New Patient Questionnaire and Patient/Guarantor Statement (Brigham and Women’s Hospital, Department of Obstetrics and Gynecology) Completed Form Examples and Samples

Subject: Intake Summary: Sarah Jenkins (DOB 05/12/1993) - New Patient for Dr. Eleanor Vance

Date of Interview: July 10, 2026

Patient Name: Sarah Jenkins. She prefers to be called Sarah and uses she/her pronouns. Age: 33. Her cell phone number is 617-555-1234 and her email is [email protected]. Her primary care provider is Dr. Emily White at Brigham Women's Primary Care in Boston. Sarah was referred to the Center for Infertility & Reproductive Surgery by her OB/GYN, Dr. Anya Sharma, at Women's Health Associates. Her first appointment with Dr. Eleanor Vance is scheduled for July 15, 2026, at 10:30 AM, in the Main Building, Suite 3B. The primary reason for her visit is primary infertility, as she and her partner have been trying to conceive for two years.

Partner Information: Her partner is Mark Thompson, born August 20, 1991, making him 35 years old. He works as a Software Engineer. Mark has no children from this or any previous relationships. He reports no significant past medical history or surgeries. He takes no regular medications and drinks about 3 alcoholic beverages per week, primarily beer. He does not smoke cigarettes.

Reproductive History (Patient): Sarah's last menstrual period began on June 28, 2024. She had her first period at age 13. Her cycles are typically every 28-30 days and last for 5 days. She has experienced two pregnancies, both with her current partner: a miscarriage in 2022 at 8 weeks, and an ectopic pregnancy in 2023 which was treated with methotrexate. She has previously consulted with Dr. Alan Reed at Mass General Fertility Center in 2023 for reproductive issues.

Symptoms: She experiences mild abdominal/pelvic pain with her periods but no pain without periods, no pain during intercourse, no bleeding or spotting between periods, no discharge from breasts, and no significant change in weight over the past year. She also notes no changes in scalp or body hair. She does not use personal lubricants.

Diagnostic Testing: Recent blood work (May 2024) shows FSH 7.2 mIU/mL, TSH 2.1 mIU/L, Estradiol 55 pg/mL, and Prolactin 18 ng/mL. Her Day 21 Progesterone in June 2024 was 12 ng/mL. She is immune to German Measles (titer 1:64 in 2010) and Chicken Pox (from infection in 2005). An HSG in July 2023 showed normal, clear fallopian tubes. Mark's semen analysis in August 2023 was normal.

Previous Fertility Treatment: Sarah underwent two cycles of IUI with Clomid in 2023. She previously used combination birth control pills from 2018-2021 for endometriosis management.

Past Gynecological History: Her last Pap smear was normal on January 15, 2024. She did have an abnormal Pap smear in 2017 (CIN I) which was treated with a LEEP procedure. She has no history of STDs or pelvic inflammatory disease. She is unsure if her mother took DES during pregnancy.

Past Medical History: Sarah manages anxiety and mild depression with therapy, which she began in 2022 after her miscarriage, and continued for general anxiety starting in 2023. She was diagnosed with endometriosis during a laparoscopy in March 2021 at Brigham and Women's Hospital, where ablation was performed. She experiences occasional migraines, sometimes with visual changes, and reports occasional heartburn. No history of anemia, arthritis, bowel problems, breast problems, breathing problems/asthma, cancer, diabetes, eating disorder, heart disease, high blood pressure, jaundice/hepatitis, kidney problems, urinary leakage, neurological disorders, skin disorders, thyroid problems, or varicose veins.

Allergies: Penicillin (hives) and Latex (rash).

Medications: Currently taking Prenatal Vitamin (daily), Folic Acid 1mg (daily), Vitamin D 2000 IU (daily), and Sertraline 50mg (daily).

Family Medical History: Her mother (62) has Type 2 Diabetes and Hypertension. Her father (65) had a heart attack at 58. Maternal grandmother (88) has Alzheimer's and osteoporosis. Maternal grandfather (deceased at 90) had lung cancer. Paternal grandmother (85) has thyroid issues. Her sister Emily (30) has PCOS. Her brother David (32) is healthy.

Social History: Sarah is married and has been with Mark for five years. She works as a Marketing Manager. Current life stressors include job demands and the emotional journey of fertility treatment. She feels safe at home and has no history of falls or feeling unsafe in relationships. She confirms understanding of germ prevention and surgical safety protocols.