The only Board Certified Fertility specialist in San Antonio Stone Oak area



 
 
 

 
  

 

Are You?

Male

Female

Your approximate age:  
How many months have you been trying to conceive:
(Enter "0" if you are not trying)		  
How many times have you been pregnant?
(include miscarriages, ectopics & terminations):		  
How many times have you delivered a liveborn baby?  
How many pregnancies has your partner fathered?:  

 
Please describe your previous pregnancies. Enter the year they occurred.(Year) How many weeks did you carry the pregnancy(Duration)? Did you deliver (DEL), have a cesarean (CS), miscarriage (SPAB) ectopic pregnancy (ECT) or terminate the pregnancy(TAB)? Enter the appropriate outcome. Did you have fertility problems(Infertility)? Enter Y/N. And, did your present partner father that pregnancy(Present) Enter Y/Npotential
 
Year  Duration(wks)  (DEL CS SPAB ECT TAB)  Infertility  Present male
 
 
 
Where do you live? (City State Country):  
 
 
Reproductive Medicine Problems
 
Endometriosis
Pelvic Adhesions
Previous Ectopic Pregnancy
Absent/Blocked fallopian Tube(s)
Absent/irregular periods
Abnormal Semen Analysis
Recurrent Pregnancy Lost
Premature Menopause
Abnormal postcoital test
Fribroid Tumors
PMS
Breast Discharge
Abnormal FHS, TSH, Prolactin or Progesterone Levels
Imunne Abnormalities
 
 
Fertility Treatments you have tried include (please check all that apply):
 
 
Clomid, Serophene, clomiphene
How many cycles?
 
0
1 to 3
4 to 6
7 to 12
More than 12
 
 

Gonadotropins injectable medication
(Bravelle®, Menopur®, Repronex®,  Gonal-F®, Follistim®, Pergonal®)
How many cycles?

0

1 to 2

3 to 4

5 to 6

More than 6
 

Intrauterine insemination
How many cycles? (Total all cycles, without ovulation induction, clomiphene and pergonal/metrodin cycles).

0

1 to 3

4 to 6

7 to 12

More than 12

 

IVF, GIFT, ZIFT
How many cycles?

0

1 to 2

3 to 4

5 to 6

More than 6

 
 
Donor sperm
Donor Egg
Laparoscopic surgery
 
Type your question in the Email response box (150 words or less).

 
The information provided in return is not intended as a substitute for medical advice of physicians. The reader should regularly consult a physician in matters relating to your health and particularly with respect to any symptoms that may require diagnosis or medical attention.
 
What is YOUR First & Last Name
(This field is required)
 
 
Street Address
 
 
Daytime phone number with area code (U.S. only)
 
 
Email address
(This field is required for a response. Please check for accuracy).
 
 
 

 

  
 


(210) FER-TILE / (210) 337-8453
19296 Stone Oak Parkway, San Antonio, Texas, 78258
info@rmatx.com
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