Height 4' 5' 6' 1" 2" 3" 4" 5" 6" 7" 8" 9" 10" 11" Weight (in pounds)

Do you smoke?

No
Yes

How many sexual partners have you had in the last six months?

0
1
2 or more

Have you ever been an egg donor or surrogate for any other program?

No
Yes

If yes, where:

What is your maritial status?

Single
Married
Divorced
Separated
Widowed

What is your ethnic background?

American Indian or Alaskan Native

Persons having origins in any of the original peoples of North America and who maintain cultural identification through tribal affiliation or community recognition.

White, Not of Hispanic Origin

Persons having origins in any of the original people of Europe, North African, or the Middle East

African-American and Black, Not of Hispanic Origin

Persons having origins in any of the Black racial groups of Africa

Asian of Pacific Islander --

Person having origins in any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent, or the Pacific Islands. This area includes, for example, China, Japan, Korea, the Philippine Islands, and Samoa.

Latino or Hispanic

Persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish Culture or origin, regardless of race.

Are you taking any mediciations?

No
Yes If so, please list them:

Do you have any illnesses?

No
Yes If so, please list them:

Do you use birth control?

No
Yes

If yes, what form of birth control do you use? Check all that apply.

Abstinence
Withdrawal
Barriers (Condoms) and Spermicides
IUDs
Birth Control Pills
Birth Control Patch
Depo-Provera and Other Long-Acting Progestin Contraceptives
Tubal Ligation
Norplant Implants
Other

How many times have you been pregnant?

Never
1
2
3
more than 3

Are you adopted?

No
Yes

Have you lived or traveled outside of the United States for more than 3 months in the last year?

No
Yes

Have you been treated by a therapist, social worker or psychiatrist?

No
Yes
If yes, for what reason?

Do you use drugs?

No
Yes

If so, how often?

Monthly or less
Two or four times/month
Two or three times/week
Four or more times/week

How often do you have a drink containing alcohol?

Never
Monthly or less
Two or four times/month
Two or three times/week
Four or more times/week

How many drinks containing alcohol do you have on a typical day when you are drinking?

1 or 2
3 or 4
5 or 6
7 - 9
10 or more

Have you ever had a sexually transmitted disease?

No
Yes
Not sure

If yes, please specify. Check all that apply.

Gonorrhea
Syphillis
Chlamydia
Genital Warts
Herpes
Other: please list :

Patient information:

Legal name of patient (last, first, middle initial):

Telephone number(s)--please include area code:

Days:        
Evenings:  
Other:      

Best time to call: a.m. p.m.

May we leave a message on your voicemail or answer machine? Yes No

Maiden or former name, if applicable (last, first, middle initial):

Street address:

City: State: Iowa Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip code:

E-mail address: