REPRODUCTIVE HISTORY
Age of Onset of Menstrual Cycle:
*
10
11
12
13
14
15
16
17
18
19
20+
Please Explain:
*
Cycle Length (How Many Days From Your Period Stopping Until It Starts Again):
*
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Days of Flow (Number of Days from Period Starts Until Period Ends)
*
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
If Yes, Please Explain:
*
If No, Please Explain:
*
How Often? By What Date Do You Plan to Stop?
*
By Date, Please Describe the Circumstances of Each Individual Miscarriage/Abortion:
*
By Date, Please List All Pregnancies Resulting in Delivery, Beginning with Date of Delivery (MM/DD/YYYY), Weight (Pounds & Ounces), Gestational Age (Weeks and Days), Sex, Method of Delivery (Vaginal/C-section), Hours in Labor, and Any Complications.
*
By Date, Please Describe Each Individual Pregnancy Complication (e.g., Premature Birth, Stillbirth, Pre-Term Labor, Gestational Diabetes, Placentia Previa, Home Monitoring, etc.) or anything exceptional about any of your pregnancies:
*
For Each Instance of Bed Rest During Your Own Pregnancy, List Extent (Moderate, Complete, Etc.), Length of Time and Under What Circumstances:
*
For Each Instance of Being Placed on Disability During Your Own Pregnancy, List Extent (Moderate, Complete, Etc.), Length of Time and Under What Circumstances:
*
Please Explain:
*
Please Explain:
*
For Each Instance of Physician-Ordered Bed Rest During Surrogate Pregnancy, List Extent (Moderate, Complete, Etc.), Length of Time and Under What Circumstances:
*
Date of Your Most Recent OB/GYN Appointment
*
Date of Your Most Recent Pap Smear
*
Please Explain:
*
Please Explain, Including Date(s), Treatment(s) and Outcomes:
*
Cell Phone
*
ALTERNATE CONTACT PERSON #1 – First and Last Name:
*
Relationship to You:
*
Cell Phone
*
ALTERNATE CONTACT PERSON #2
*
Relationship to You:
*
Cell Phone
*
ALTERNATE CONTACT PERSON #3
*
Relationship to You:
*
Cell Phone
*
If you are human, leave this field blank.