Second Opinion

RGI provides you the ability to obtain a second opinion. Only after we have received the information requested below, and any appropriate medical records, can the specialist begin to formulate a recommendation. After we receive your information, we will contact you to review the costs for an electronic second opinion and other medical records that may be necessary to forward to our physicians.

Contact Information:

Female Name:

Female Date of Birth: (mm/dd/yyyy)

Male Name:

Male Date of Birth: (mm/dd/yyyy)

Address 1:

Address 2:

City:

Zip:

Home Phone:

Daytime Phone: *

email: *

Alternate Phone:

Referral Source:

A friend or another donor - Name:

A patient of IHR - Name:

Advertisement - Where:

online

Principal Reason for Consultation:

How many years have you been trying to become pregnant:

How many times have you had repeated pregnancy loss:

List last four pregnancy outcomes:
Date	Outcome	If Misc	If Mis	If Misc	If Misc

Are you seeking a second opinion:Yes No

If yes, please explain why:

Is there any other reason(s) for consultation:

Menstrual History:

How old were you when you first began to menstruate:

Other:

How many days are there (usually) between one period to the next? 26-28 29-32 Other:

How many days does your periods usually last? 2-3 4-5 6-8 Other:

Do you ever experience mid-cycle bleeding?YesNo

Your last menstrual period started on what date?

Grade your pain level you experience with your menstrual period as: Low Moderate High Very High

Would you describe your menstrual cycle as:RegularIrregular

In general, how heavy is your menstrual flow? Light Moderate Heavy Very Heavy

Have you had a Pap Smear within the past 6 months? Yes No

Was result of your Pap Smear within normal limits? Yes No

Have you had a mammagram within the past 6 months? Yes No

Was result of your mammagram within normal limits? Yes No

Have you ever taken, or are you currently taking oral contraceptives? Yes No

If yes, what brand and for how long?

What methods of contraceptive have you used? Please list and date last used:

Have you ever experienced pain with sexual intercourse? Yes No

If yes, please describe the pain:

Medical and Surgical History:

Have you been surgically sterilized? Yes No

If yes, please describe:

Have you had any other surgeries in the past? Yes No

If yes, please indicate what surgeries you have had:

Have you ever had an adverse reaction to general anesthetics? Yes No

If yes, please indicate what happened, and the severity of the response:

Have you ever been hospitalized for anything other than the above listed surgeries? Yes No

If yes, please tell us why you were hospitalized:

Are you allergic to any medications? Yes No

If yes, please tell us what medication you're allergic to:

Do you have any dietary restrictions? Yes No

If yes, what are your dietary restrictions, and for what reason?

Do you take any supplemental vitamins or herbal remedies on a continual basis? Yes No

If yes, please list what vitamins or herbal remedies you are taking:

Do you take any prescription or over the counter medication on a regular or continual basis? Yes No

If yes, please list what medication you are currently taking:

Do you exercise regularly? Yes No

Have you ever been told in the past, that you have had any of the following? (check all that apply):
Abnormal Pap Smear	Hepatitis A, B or C
Acne	Herpes Simplex Virus I or II
AIDS	High Blood Pressure
Allergies	Hypertension
Anemia	Intolerance to hot/cold
Alzheimer's Disease	Jaundice
Anorexia	Kidney Disease
Appendicitis	Loss of Libido
Arthritis	Loss of Scalp Hair
Autoimmune Disorder	Measles
Colitis	Multiple Sclerosis
Blocked Fallopian Tubes	Neurologic Problems
Breast Cancer	Nongonococcal Urethritis
Breast Masses	Ovarian Cancer
Breast Secretions	Ovarian Cysts
Bronchitis	Pain with Intercourse
Cancer	Parasitic Infections
Cervical Cancer	Pelvic Inflammatory Disease
Chlamydia	Pneumonia
Chronic cough	Polycystic Ovarian Syndrome (PCOS)
Chronic Pelvic Pain	Poor Sense of Smell
Condyloma	Psychiatric Care
Diabetes	Rheumatic Fever
Endocrine Disease	Scarlet Fever
Endometriosis	Seizures
Gonorrhea	Sexually Transmitted Disease
Epilepsy	Syphilis
Excessive Hair Growth	Thyroid Problems
Excessive Sweating	Transfusion Problems
Excessive Weight Change	Tuberculosis
Fibroids	Ulcers
Dizziness	Ureaplasma/Mycoplasma
Frequent Headaches	Vaginitis
Gallbladder Disease	Visual Disturbances
Heart Disease

Have you ever been excluded from blood donation? Yes No

If yes, please explain when and why:

Psychological History:

Have you ever sought counseling for depression or emotional problems? Yes No

Have you ever taken antidepressants for more than three months at a time? Yes No

Have you ever been diagnosed as having any of the following (please check all that apply)

Depression

Schizophrenia

Manic Depression

Obsessive-Compulsive Disorder

Mania

Anorexia or Bulimia

Self Mutilation

Have you ever received Pituitary derived growth hormone? Yes No

Family History:

Are there any genetic abnormalities or birth defects in family? Yes No

If yes, please describe:

Relative	Alive?	Age or age at death	Any medical Problems
Mother	YesNo
Maternal Grandmother	YesNo
Maternal Grandfather	YesNo
Father	YesNo
Paternal Grandmother	YesNo
Paternal Grandfather	Yes No
Sibling 1	YesNo
Sibling 2	Yes No
Your Own Child 1	YesNo
Your Own Child 2	YesNo

Please indicate if any family member has any conditions listed below. Check all that apply:

Condition	Self	Family	Who in the Family?
Cleft Palate	No	YesNo
Spina Bifida	No	YesNo
Thyroid Disease	No	YesNo
Clubfoot	No	YesNo
Mental Retardation	No	YesNo
Down's Syndrome	No	YesNo
Cystic Fibrosis	No	YesNo
Marfan Syndrome	No	YesNo
Albinism	No	YesNo
Muscular Dystrophy	No	YesNo
Cancer (indicate type)	No	YesNo
Schizophrenia	No	YesNo
Clinical Depression	No	YesNo
Obsessive-Compulsive Disorder	No	YesNo
Mania	No	YesNo
Tay Sachs Disease	No	YesNo
Canavan's Disease	No	YesNo
Hemolytic Anemia	No	YesNo
Blindness	No	YesNo
Hearing Impairment	No	YesNo
Color Blindness	No	YesNo
Heart Disease	No	YesNo
Parkison's Disease	No	YesNo
Hemochromotosis	No	YesNo
High Cholesterol	No	YesNo
Sickle Cell Anemia	No	YesNo
Hemophilia	No	YesNo
Huntington's Disease	No	YesNo
Diabetes	No	YesNo
Multiple Sclerosis	No	YesNo
Alzheimer's Disease	No	YesNo
Infertility	No	YesNo
Recurrent Miscarriage	No	YesNo
Liver Disease	No	YesNo
High Blood Pressure	No	YesNo
Asthma	No	YesNo
Epilepsy	No	YesNo
Tourette's Syndrome	No	YesNo
Attention Deficit Syndrome	No	YesNo
Still Born Babies	No	YesNo
Sudden Infant Death Defects	No	YesNo
Hermaphrodism	No	YesNo
Death before age 40	No	YesNo
Addiction (indicate type)	No	YesNo
Clinical Osteoporosis	No	YesNo

Ethnicity (check all that apply):
Aborigine	African
Asian	South Asian
Caucasian	Hispanic
Indonesian	Mediterranean
Native American	West Indian
Other	Enter Other:

Please select your ancestry and provide the percentage. You can add up to 8 ancestries
	%
	%
	%
	%
	%
	%
	%
	%

Social History:

Tobacco (Check all that currently apply): currently smoke heavy smoker used to smoke never smoked

Alcohol

I never drink alcohol

I drink times per week

I rarely drink alcohol (less than twice a year)

Drug usage:

I have never used illegal drugs

I have tried illegal drugs at least once in the past

I used to do drugs regularly but don't anymore

I am currently using one or more of the following:

Enter usages:

Have you ever used injectable drugs? Yes No

If yes, when did you last use injectable drugs?

Describe your profession:

Are you aware of any other health problems in your self, family or partners not already disclosed? Yes No

If yes, please indicate those problems: