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

Enter any additional family medical history information not captured above, including relatives' relationships, ages or ages at diagnosis, and specific medical conditions or relevant details.

Enter any additional notes or comments relevant to this form on this line.

Enter any additional notes or comments relevant to this form on this top line.

Enter any additional social history information or recent life stressors relevant to your care (for example: details about relationships, living situation, occupation, substance use, or other psychosocial factors).

Enter the typical number of alcoholic drinks you consume in an average week (provide a numeric count, e.g., 0, 1, 7).

Enter all known allergies (medications, latex, foods, environmental, etc.) and briefly describe the reaction for each (e.g., rash, difficulty breathing, GI upset).

Enter the name of the clinician or provider scheduled for this appointment.

Enter the scheduled time of the appointment (including AM or PM).

Enter the scheduled calendar date of the appointment.

Enter any additional appointment details such as clinic location, room, or special instructions provided with your appointment notice.

List the birth control method(s) you have used (for example: combination pill, progestin-only pill, IUD, implant, patch, ring, injection, condoms), separated by commas if more than one. Fill only if 'Have you used birth control? (box 2)' is 'Yes'.

Provide any additional relevant details about your birth control use such as brand names, dates or duration of use, typical dose, reason for stopping, or other notes.

Check this box to indicate the appropriate response to the question 'Have you used birth control?' as printed on the form (use the specific box that corresponds to the patient’s answer).

Check this box to indicate the appropriate response to the question 'Have you used birth control?' as printed on the form (use the specific box that corresponds to the patient’s answer).

Check this box to indicate the appropriate response to the question 'Have you used birth control?' as printed on the form (use the specific box that corresponds to the patient’s answer).

Enter the first brother's age and any relevant medical conditions or health issues (e.g., 'Age 45 — high blood pressure, diabetes').

Enter the second brother's age and any relevant medical conditions or health issues (e.g., 'Age 42 — asthma, heart disease').

Enter any additional notes, remarks, or information relevant to your medical record that were not captured elsewhere on this form.

Enter how long you have been with your current partner (for example, '3 years', '6 months', or '2 years 4 months'). Fill only if 'PARTNER (if applicable)' indicates a current partner.

Check this box if you currently have a partner and will provide the length of time you have been together in the adjacent space. Fill only if 'PARTNER (if applicable)' indicates a current partner.

Briefly describe any current or recent stressful events, problems, or circumstances in your life (for example: relationship issues, job loss, financial problems, health concerns, bereavement, legal matters, etc.).

Enter the patient's FSH (Follicle Stimulating Hormone) lab result for Diagnostic Test Row 1; include the units or reference range if available.

Check this box when the FSH blood test is relevant and has been ordered or performed for the patient.

Check this box if a laparoscopy was performed and you are recording or reporting the laparoscopic findings on this form.

Enter the hysteroscopic findings observed during the procedure (brief free-text description of any lesions, adhesions, polyps, uterine cavity appearance, or other notable observations).

Check this box if a hysteroscopic examination was performed and there are findings to record in the adjacent text field.

Check this box if a semen analysis has been performed or ordered for the patient (use the adjacent line to record date/results as needed).

Enter the name or brief description of any other diagnostic test or finding not listed above (e.g., test type, date, result summary or relevant details).

Check this box when a diagnostic test not listed above was performed; provide the test name or details on the adjacent line.

Enter the thyroid-stimulating hormone (TSH) test result for Diagnostic Test Row 2 as reported by the laboratory.

Check this box when the TSH (thyroid-stimulating hormone) blood test was ordered or performed for the patient.

Enter the patient's estradiol laboratory result as reported on the diagnostic test, including the units (e.g., pg/mL or pmol/L) if available.

Enter the prolactin test result as reported on the lab report, including the units if available.

Check this box if a Prolactin blood test was performed or is being ordered for the patient.

Enter the progesterone test result from the diagnostic blood test (the measured value reported by the laboratory).

Check this box if a progesterone blood test was performed, ordered, or should be indicated on the diagnostic testing list.

Enter the German Measles (Rubella) diagnostic test result as a short text value (for example: Positive, Negative, Immune, or an antibody titer with units such as 1:64 or 10 IU/mL).

Check this box if a diagnostic test for German measles (rubella) was performed; use the adjacent line to record the test result, date, or any relevant notes.

Enter the chicken pox test information or result for this patient (for example: positive/negative, IgG/IgM titer value, date performed, or other relevant notes).

Check this box if a diagnostic test for chicken pox (varicella) was performed or is being reported on this form.

Enter the Hysterosalpingogram (HSG/Tubogram) findings or result information (for example: normal/abnormal, tubal patency, brief summary of findings or relevant notes).

Check this box when a hysterosalpingogram (HSG/tubogram) has been performed or is being ordered for the patient.

Enter any additional diagnostic testing details, observations, or brief free-text notes related to the tests listed above (e.g., results, dates, or clarifying information).

Provide further diagnostic testing information or continue notes from the previous line, such as other tests performed, specific findings, or remarks for the medical record.

Check this box if the patient has the fifth diet or nutrition problem listed on the form.

Check this box if the patient has the second diet or nutrition problem listed on the form.

Check this box if the patient has the third diet or nutrition problem listed on the form.

Check this box if the patient has the fourth diet or nutrition problem listed on the form.

Check this box if the patient has the first diet or nutrition problem listed on the form.

Check this box if the patient has the sixth diet or nutrition problem listed on the form.

Enter the short reference, identifier, or brief note for the estimate being acknowledged (for example an estimate ID, code, or short descriptive label).

Provide additional details or continuation of the father's age and medical problems, including treatments, ages at diagnosis, or other relevant health notes.

Enter the father's age and any medical conditions or diagnoses (e.g., 'Age 68 — heart disease, diabetes') to begin listing his family medical history.

Enter how many times per day you take this medication (for example, "1", "2", or "1.5" if you take it once and a half times per day).

Enter the medication name and its dosage together (for example, "Lisinopril 10 mg" or "Metformin 500 mg").

Enter the document’s header identifier or label shown at the top of the form (for example a form number, code, or short title used to identify this specific page).

Enter a short description of any problems with sexual performance (for example erectile dysfunction or low libido), including onset, frequency, and any factors or treatments related to the issue.

Check this box if you do not currently feel safe at home.

Check this box if you currently feel safe at home.

Enter your current marital status (for example: Single, Married, Divorced, Separated, Widowed, or Domestic Partnership).

List any medical conditions, diagnoses, surgeries, medications, or other relevant health information for the maternal grandfather, including ages at diagnosis when known.

Enter the maternal grandfather's current age or age at death.

Enter any additional details about the maternal grandmother's age or medical problems that continue from the previous line.

Enter the maternal grandmother's age and any medical conditions or relevant medical history information on this first line.

Enter how long you have been trying to become pregnant (for example, '6 months' or '2 years').

Enter the age in years when you had your first menstrual period.

Enter the typical number of days your menstrual bleeding lasts.

Describe how often your menstrual cycles occur (for example, 'every 28 days' or 'monthly').

Enter the first day of your most recent menstrual period.

Provide any additional age or medical history details for the mother that did not fit on the primary line, such as more diagnoses, treatments, or clarifying notes.

Enter the mother's age and any current or past medical problems, listing diagnoses, conditions, or relevant health notes for the mother.

Enter your current job title or, if not currently employed, your most recent occupation (briefly describe the role or position).

Enter the other physician's full name and the date(s) and clinic/hospital location where you saw them for reproductive issues. Fill only if 'Changes in scalp or body hair — separator (slash)' is 'Yes'.

Check this box if you have previously seen another reproductive physician and you are listing that provider as previous physician entry #1 in the space below.

Check this box if you have previously seen another reproductive physician and you are listing that provider as previous physician entry #4 in the space below.

Check this box if you have previously seen another reproductive physician and you are listing that provider as previous physician entry #2 in the space below.

Check this box if you have previously seen another reproductive physician and you are listing that provider as previous physician entry #3 in the space below.

Enter the number of children the partner has with the current relationship.

Enter the average number of cigarettes the partner smokes per day.

List any prior surgical procedures the partner has had, including the procedure and year if known.

Enter the number of children the partner has from relationships other than the current one.

Enter the partner's date of birth.

List significant past or chronic medical conditions, diagnoses, or ongoing health problems the partner has.

Enter the partner's full name as it should appear in medical records.

Provide the average number of alcoholic drinks the partner consumes per week.

Provide the partner's current job title or occupation.

Enter the partner's medical record number assigned by the facility.

List all prescription and over‑the‑counter medications, vitamins, and supplements the partner is currently taking, including dosages if known.

Enter any other relevant partner information or comments not captured in the fields above.

Enter the date of your most recent mammogram.

Enter the findings from that mammogram (for example: normal, abnormal, any noted masses, calcifications, or recommendation for follow-up) as a short text description.

Enter the endometrial biopsy information such as date and brief findings or result summary (e.g., normal, hyperplasia, atrophic).

Enter the semen analysis result summary including relevant details (e.g., sperm count, motility, morphology and any overall interpretation).

Check this box only if it corresponds to your answer to the question “Did your mother take DES while pregnant with you?” as indicated on the printed form (select the box labeled for your response).

Check this box if you do not know whether your mother took DES while she was pregnant with you (the printed form labels this option “Don’t Know”).

Check this box only if it corresponds to your answer to the question “Did your mother take DES while pregnant with you?” as indicated on the printed form (select the box labeled for your response).

Check this box only if it corresponds to your answer to the question “Did your mother take DES while pregnant with you?” as indicated on the printed form (select the box labeled for your response).

Check this box only if it corresponds to your answer to the question “Did your mother take DES while pregnant with you?” as indicated on the printed form (select the box labeled for your response).

Check this box only if it corresponds to your answer to the question “Did your mother take DES while pregnant with you?” as indicated on the printed form (select the box labeled for your response).

Enter the date of your most recent Pap smear.

If you have had an abnormal Pap smear, enter when it occurred and describe any treatment(s) you received; leave blank if not applicable. Fill only if 'Bowel problems — details' is 'Yes'.

Check this box if the patient is unsure or does not know whether they have had an abnormal Pap smear.

Check this box if the patient has previously had an abnormal Pap smear.

Check this box if the patient has never had an abnormal Pap smear.

Provide a concise summary of any findings observed during laparoscopy, including abnormalities, locations, and relevant details (e.g., adhesions, endometriosis, cysts).

Enter the name(s) or description of any personal lubricants you use, including brand, type, or formulation (e.g., water‑based, silicone‑based). Fill only if 'Heart disease — details' is 'Yes'.

Check this box to indicate the patient has NOT had pelvic inflammatory disease (alternate/duplicate checkbox for the No response).

Check this box to indicate the patient is UNSURE or does not know whether they have had pelvic inflammatory disease (additional/duplicate Don't Know checkbox).

Check this box to indicate the patient has NOT had pelvic inflammatory disease (select if the answer is No).

Check this box to indicate the patient is UNSURE or does not know whether they have had pelvic inflammatory disease.

Check this box to indicate the patient is UNSURE or does not know whether they have had pelvic inflammatory disease (alternate/duplicate checkbox for the Don't Know response).

Check this box to indicate the patient HAS previously been diagnosed with or experienced pelvic inflammatory disease (select if the answer is Yes).

Check this box to indicate the patient HAS previously been diagnosed with or experienced pelvic inflammatory disease (alternate/duplicate checkbox for the Yes response).

If you have ever been diagnosed with a sexually transmitted disease, enter the diagnosis(es) and any relevant details such as condition name(s), date(s) of diagnosis, and brief treatment or outcome information; if none, leave blank or write 'N/A'. Fill only if 'choicebutton_1_133_18a62e41' is 'Yes'.

Provide details of any breast problems, including lumps, biopsies, surgeries, dates, diagnoses, or treatments.

List bowel-related problems (constipation, diarrhea, colitis, etc.), including onset, frequency, diagnosis, and any treatments or medications.

Provide information about any depression diagnosis, including onset, treatments, medications, and whether therapy was or is being used.

Enter details about any diabetes, specifying type (Type 1 or Type 2), date of diagnosis, medications (insulin/oral), and complications if any.

Describe any eating disorder history, including type, duration, treatments, hospitalizations, or current management.

Enter any brief additional past medical information or clarifying note related to the nearby conditions (e.g., severity, timeframe, or treatment).

Describe any arthritis you have had, specifying the type (e.g., osteoarthritis, RA), affected joints, dates, and treatments.

List any cancer diagnoses, including type, site, date(s) of diagnosis, treatments (surgery/chemo/radiation) and current status.

Provide details about headaches or migraines, including type, frequency, triggers, treatments, and any neurologic workup.

List any heart disease or cardiac conditions, including diagnosis, procedures, medications, dates, and current status.

Provide information about any anxiety disorder, including diagnosis date, symptoms, treatments, medications, or therapy received.

Describe any breathing problems or asthma, including diagnosis date, triggers, medications (inhalers), and hospitalizations.

Enter details about any anemia diagnosis, including approximate date(s), severity, treatments, medications, or transfusions.

Enter any other past medical conditions or concise additional notes not captured above.

Check this box if you have experienced breast problems (lumps, pain, surgery, etc.); use the line to describe.

Check this box if you have any bowel problems such as constipation, diarrhea, colitis, or similar; explain the condition on the line.

Check this box if you have ever been diagnosed with cancer; list the type, date, and treatment on the line.

Check this box if you have diabetes (type 1 or type 2) or a history of impaired glucose/insulin issues; note type and management on the line.

Check this box if you suffer from frequent or chronic headaches or migraines; describe frequency and treatment on the line.

Check this box if you have a history of anxiety or anxiety-related disorders or are currently experiencing anxiety; describe on the line.

Check this box if you have ever been diagnosed with or treated for anemia; use the adjacent line to give details.

Check this box if you have a history of depression or depressive episodes; describe treatment or current status on the line.

Check this box if you have asthma or other chronic breathing or respiratory problems; provide details on the line.

Check this box if you have heart disease or other cardiac conditions (heart attack, angina, CHF, etc.); list specifics and dates on the line.

Check this box if you have a history of an eating disorder (e.g., anorexia, bulimia, binge-eating); provide details on the line.

Check this box if you have been diagnosed with arthritis (for example osteoarthritis or rheumatoid arthritis); provide specifics on the line.

Enter details about any kidney problems, including diagnosis, when it occurred, treatments, ongoing issues, and current status.

Provide information about any history of jaundice or hepatitis, including type, dates, treatments, and outcomes.

Describe episodes of migraines with visual changes, noting frequency, typical symptoms, duration, and treatments tried.

List any neurological or brain disorders you have been diagnosed with, including diagnosis name, date, symptoms, and treatments.

Provide details about stomach or gastrointestinal problems (e.g., hernia, ulcer, chronic heartburn), including diagnoses, dates, and treatments.

Describe any urinary leakage with coughing, sneezing or physical activity, including frequency, severity, and treatments or management steps.

Enter information about high blood pressure, including diagnosis date, typical readings if known, medications, and control status.

Summarize any history of urinary tract infections, noting frequency, dates, organisms if known, and treatments received.

Provide details of any thyroid conditions, including diagnosis (hypo-/hyperthyroidism), dates, test results, and current medications.

Describe any varicose veins, including location, symptoms, treatments or procedures, and whether they are ongoing.

List any skin disorders or chronic dermatologic conditions, including diagnoses, affected areas, treatments, and current status.

Provide information about migraine headaches (without visual changes), including frequency, triggers, severity, and treatments.

Describe any other medical conditions not listed above, including diagnosis, dates, treatments, and current status.

Check this box if you have any other past medical conditions not listed above and write them on the provided line.

Check this box if you have been diagnosed with a thyroid disorder (hypothyroidism, hyperthyroidism, thyroiditis, etc.).

Check this box if you have chronic or significant skin conditions (for example eczema, psoriasis, severe dermatitis, etc.).

Check this box if you have varicose veins or chronic venous insufficiency.

Check this box if you have been diagnosed with or currently have high blood pressure (hypertension).

Check this box if you have a history of urinary tract infections.

Check this box if you have had jaundice or a diagnosis of hepatitis (any type).

Check this box if you have had stomach or upper GI issues such as hernia, peptic ulcer disease, chronic heartburn/GERD, or similar conditions.

Check this box if you experience urine leakage with coughing, sneezing, laughing, or physical exertion (stress incontinence).

Check this box if your migraines are accompanied by visual disturbances (for example, aura or other vision changes).

Check this box if you have any neurological conditions (such as seizure disorder, stroke, multiple sclerosis, or other brain disorders).

Check this box if you have or have had kidney disease, reduced kidney function, or other kidney problems.

Check this box if you have a history of migraine headaches.

Enter the surgical procedure name and the date it was performed (month/day/year or month & year) and any brief details (reason, hospital or surgeon) for the fourth past surgery.

Enter the surgical procedure name and the date it was performed (month/day/year or month & year) and any brief details (reason, hospital or surgeon) for the second past surgery.

Enter the surgical procedure name and the date it was performed (month/day/year or month & year) and any brief details (reason, hospital or surgeon) for the third past surgery.

Enter the surgical procedure name and the date it was performed (month/day/year or month & year) and any brief details (reason, hospital or surgeon) for the first past surgery.

Enter the paternal grandfather’s age and primary medical problems or diagnoses on this first line (e.g., age and major conditions).

Enter any additional medical conditions, treatments, or notes about the paternal grandfather on this second line.

Enter the paternal grandmother’s current age or age at death and any short status note (e.g., living, deceased).

List the paternal grandmother’s significant medical conditions, diagnoses, and relevant health history (include ages at diagnosis if known).

Enter your personal email address used for appointment communications.

Enter your primary cell phone number, including area code, for contact about appointments.

Enter the name and/or pronouns you prefer staff to use when addressing you.

Enter your date of birth.

Describe how you heard about the Center for Infertility & Reproductive Surgery (for example: referral, website, friend).

Enter your full legal name as it appears on official records.

Provide the full name of your primary care provider and the clinic or location where they practice.

Enter your current age in years.

Briefly state the primary reason or concern for this visit.

Enter the date when the patient signed the attestation.

Enter the time (AM or PM) when the patient signed the attestation.

Enter the patient's full signature to attest that all questions have been answered to the best of their ability.

Enter the date on which the patient signed this consent form.

Enter the time at which the patient signed this consent form (include AM or PM).

Enter the patient’s full legal signature to confirm consent for release/access to mental health notes and related treatment information.

Enter the patient's Medical Record Number (MRN) assigned by the hospital.

Enter the date the patient signed this statement.

Provide the patient's signature to acknowledge and accept the patient/guarantor statement.

Enter the patient's full printed name legibly as the written name of the person signing.

Check this box if the first response option correctly represents your answer to 'Do you use personal lubricants?' (select the box that corresponds to your situation).

Check this box if the second response option correctly represents your answer to 'Do you use personal lubricants?' (select the box that corresponds to your situation).

Check this box if the third response option correctly represents your answer to 'Do you use personal lubricants?' (select the box that corresponds to your situation).

Check this box when the patient has a history of falls or reports problems with their balance.

Check this box to indicate 'Yes' in response to the question about history of falls or balance problems.

Check this box to indicate 'No' in response to the question about history of falls or balance problems.

Check this box to indicate 'Yes' to the follow‑up question about having balance problems while walking.

Check this box to indicate 'No' to the follow‑up question about having balance problems while walking.

Check this box when the patient specifically reports having balance problems while walking (follow‑up to the falls/balance question).

Check this box to indicate the question 'Do you currently feel safe at home?' is being asked or applies.

Check this box if the answer is Yes — the patient currently feels safe at home.

Check this box if the answer is Yes — the patient currently feels safe at home (alternate checkbox for the same Yes response).

Check this box if the answer is Yes — the patient currently feels safe at home (alternate checkbox for the same Yes response).

Check this box if the answer is No — the patient does not currently feel safe at home.

Check this far-right box when you are selecting the fourth response option for the question about understanding how to prevent the spread of germs.

Check this box to indicate that you understand how to prevent the spread of germs.

Check this right-side box when you are selecting the first response option for the question about understanding how to prevent the spread of germs.

Check this right-side box when you are selecting the second response option for the question about understanding how to prevent the spread of germs.

Check this right-side box when you are selecting the third response option for the question about understanding how to prevent the spread of germs.

Enter 'Y' or 'N' to indicate whether you understand how the medical team will keep you safe if you are having surgery or a procedure.

If you answered 'N' or have questions, provide a brief explanation or list your concerns about how you will be kept safe during the surgery or procedure; otherwise leave blank.

Check this box to indicate acknowledgement of the first line of the surgery/procedure safety question shown on the form (the lead‑in to the question about how you will be kept safe).

Check this box to indicate acknowledgement of the continuation of the surgery/procedure safety question (that staff will take steps to keep you safe during a surgery or procedure).

Check this box if you answer YES to the surgery/procedure safety question — you understand how the care team will keep you safe during a surgery or procedure.

Check this box if you answer NO to the surgery/procedure safety question — you do not understand how the care team will keep you safe and may need further explanation.

Check this box to indicate the patient was asked the question 'Have you ever felt threatened or unsafe in a relationship?' (marks the question/entry on the form).

Check this box when the patient selects the fourth response option for this question (use the box that corresponds to the fourth answer choice shown on the printed form).

Check this box when the patient selects the first response option for this question (use the box that corresponds to the first answer choice shown on the printed form).

Check this box when the patient selects the third response option for this question (use the box that corresponds to the third answer choice shown on the printed form).

Check this box when the patient selects the second response option for this question (use the box that corresponds to the second answer choice shown on the printed form).

Enter the details for the first pregnancy in chronological order, including dates and outcome (e.g., live birth boy/girl, miscarriage, stillbirth) and note if a different partner was involved.

Enter the details for the second pregnancy in chronological order, including dates and outcome (e.g., live birth boy/girl, miscarriage, stillbirth) and note if a different partner was involved.

Enter the first listed pregnancy’s information including dates and outcome (e.g., boy, girl, miscarriage, stillbirth) and note if the pregnancy was with a different partner than the present partner.

Enter the second listed pregnancy’s information including dates and outcome (e.g., boy, girl, miscarriage, stillbirth) and note if the pregnancy was with a different partner than the present partner.

Enter the details of a pregnancy (dates and outcome such as boy, girl, miscarriage, or stillbirth) and note if a different partner was involved than the present partner.

Enter the details of a pregnancy (dates and outcome such as boy, girl, miscarriage, or stillbirth) and note if a different partner was involved than the present partner.

Enter the pregnancy details (dates, outcome such as boy/girl/miscarriage/stillbirth, and any notes about partner if different from current) for this pregnancy in the right entry.

Enter the pregnancy details (dates, outcome such as boy/girl/miscarriage/stillbirth, and any notes about partner if different from current) for this pregnancy in the left entry.

Enter any additional fertility treatments, medications, or relevant details not listed above (include names, dates, duration, or brief notes about the treatment).

Check this box if you have previously been treated with Danazol as part of fertility care.

Check this box if you have previously undergone gamete intrafallopian transfer (GIFT).

Check this box if you have previously used birth control pills (as relevant to your fertility history).

Check this box if you have previously undergone intracytoplasmic sperm injection (ICSI).

Check this box if you have previously used Synarel (nafarelin) as part of fertility treatment.

Check this box if you have previously undergone in vitro fertilization (IVF).

Check this box if you have previously had intrauterine insemination (IUI) combined with injectable gonadotropins such as Gonal‑F, Follistim, or Bravelle.

Check this box if you have previously used Menopur, Repronex, or other similar injectable fertility medications.

Check this box if you have previously had IUI in combination with Clomid (clomiphene) or Serophene.

Check this box if you have previously had assisted hatching performed on embryos during fertility treatment.

Check this box if you have previously used Lupron (leuprolide) as part of fertility treatment.

Check this box if you have previously undergone intrauterine insemination (IUI).

Enter the time the provider reviewed and signed the patient's form.

Enter the date the provider reviewed and signed the patient's form.

Enter the provider's clinic identification (CID) or staff ID number used to identify the provider.

Enter the provider's full name or official signature to indicate they reviewed the information.

Check this box after the provider has signed the form and confirmed the CID #, date, and time to indicate they have reviewed and verified the information.

If you answered Yes to having used recreational drugs, list the drug names you have used (separated by commas) and any brief qualifiers such as current use or approximate timeframe. Fill only if 'If yes — Specify which drugs (free text)' is 'Yes'.

Check this box if you have used amphetamines or methamphetamine.

Check this box if you have used marijuana or hashish.

Check this box if you have used heroin or other non‑prescribed opioids.

Check this box if you have used cocaine or crack.

Check this box if you have ever used recreational drugs.

Check this box when you are providing the names of the recreational drugs you used and then write them on the line provided.

Check this box if you have used other recreational drugs and specify them on the ‘which drugs’ line.

Enter how many times per day you take the second medication (use a numeric value, e.g., '1', '2', or '3').

Enter the name of the second medication and its dosage (e.g., drug name and amount such as 'Lisinopril 10 mg').

Enter whether there are problems with sexual performance (e.g., 'Y' or 'N'); if yes, briefly describe the issue such as erectile dysfunction, low libido, frequency, onset, or severity. Fill only if 'Diagnostic Test Row 1 - FSH' is 'Yes'.

Check this box if the patient does not have any problems with sexual performance (no erectile dysfunction or low libido).

Check this box if the patient has problems with sexual performance (for example erectile dysfunction or low libido).

Enter the age(s) and any medical problems or conditions for your sister(s) on this first line (e.g., 'Jane, 45 – hypertension; Mary, 42 – healthy').

Enter additional sister ages and medical problems or conditions on this continuation line if more space is needed for listing siblings.

Check this box if, in response to the question 'Do you smoke?', you are selecting the first smoking option labeled '1' on the form.

Check this box if, in response to the question 'Do you smoke?', you are selecting the second smoking option labeled '2' on the form.

Check this box if, in response to the question 'Do you smoke?', you are selecting the third smoking option labeled '3' on the form.

Enter how often you have smoked when you did (for example, number of times per day or per week); specify the timeframe if relevant. Fill only if 'Have you ever smoked - Yes' is 'Yes'.

Check this box if you used to smoke in the past but no longer do.

Check this box if you have never smoked.

Check this box if you have ever smoked (even if you do not currently smoke).

Check this box if you do not experience abdominal or pelvic pain during your menstrual periods (answer = No).

Check this box if you experience abdominal or pelvic pain during your menstrual periods (answer = Yes).

This mark/separator is part of the Yes/No response area for the question; do not check this box separately unless the form explicitly instructs you to mark it.

Check this box (the rightmost of the three) to indicate you have experienced abdominal/pelvic pain not associated with your menstrual periods.

Check this box (the middle of the three) to indicate you have experienced abdominal/pelvic pain not associated with your menstrual periods.

Check this box (the leftmost of the three) to indicate you have experienced abdominal/pelvic pain not associated with your menstrual periods.

Check this box if the right option next to the question “Bleeding/spotting between periods?” corresponds to your answer.

Check this box if the left option next to the question “Bleeding/spotting between periods?” corresponds to your answer.

Check this box if the middle option next to the question “Bleeding/spotting between periods?” corresponds to your answer.

Check this box if the third-from-left option shown on the paper form best describes the change in your weight over the past year.

Check this box if the left-most option shown on the paper form best describes the change in your weight over the past year.

Check this box if the second-from-left option shown on the paper form best describes the change in your weight over the past year.

Check this box if the right-most option shown on the paper form best describes the change in your weight over the past year.

Check this box if you have NOT experienced changes in scalp or body hair (select No).

Check this box if you have experienced changes in scalp or body hair (select Yes).

This is the printed separator between the Yes and No choices; it is not a selectable option and should not be checked.

Check this box when the right-hand option next to the question 'Discharge from breasts?' applies to you.

Check this box when the left-hand option next to the question 'Discharge from breasts?' applies to you.

Check this box when the center option next to the question 'Discharge from breasts?' applies to you.

Check this box if you are unsure, the question does not apply, or you want to indicate a response other than Yes or No for pain during sexual intercourse.

Check this box if you currently or have ever experienced pain during sexual intercourse (answer = Yes).

Check this box if you have never experienced pain during sexual intercourse (answer = No).

Check this box if the patient is unsure or does not know whether there has been a significant change in weight.

Check this box if the patient has experienced a significant change in weight.

Check this box if the patient has not experienced a significant change in weight.

Enter how many times per day you take this third medication (a numeric count such as 1, 2, 3, etc.).

Enter the name of the third medication you take and its dosage (for example, drug name and mg or other strength).

Enter the information requested by the clinic for the top-right box (for example a patient label, barcode, clinic use notes, or other identification details).