New Patient Questionnaire

Recessive Disease Screening

Recessive conditions are conditions that result from two recessive genes being passed to a child - one from each asymptomatic parent - that cause a disease in that child. Current technological advances now make it possible to test for approximately 176 recessive conditions, each with its own severity, chance of inheritance, and sensitivity to screening. The total chance of having a child affected with one of these diseases is about 1/200, depending on the ethnicity of the parents.

The decision to screen for these diseases is a personal one and depends on each couple's philosophy and financial situation. In addition, there is a medical-legal dimension to this decision for CRM. Because of the medical-legal issues involved we must ask you to declare your decision to screen or not to screen for these conditions prior to beginning your infertility treatment. The test involves a blood test on at least one of the partners. The blood test costs $350 and is not submitted to your insurance. There is about a 60% chance that the test will show at least one recessive mutation in one of the partners. If the test shows one partner to be a carrier of a recessive condition, the other partner would have the blood test for $350 to see if both partners are carriers of the same recessive condition.

If you are both carriers for the same condition (about 2% Chance), you would have the option of doing IVF with Preimplantation Genetic Diagnosis (PGD) where each embryo you make would be tested for the condition and only embryos without the condition transferred to your uterus. IVF with PGD costs approximately $25,000.

Or you could simply conceive and have the fetus tested early in the pregnancy. If the test was positive (1/4 chance), the pregnancy could be terminated or you could prepare for a baby with the inherited condition.

A third option would be to use donor sperm or donor eggs to avoid conceiving a child with the recessive condition.

I choose to be screened and to delay infertility treatment until my results are known.
I decline screening for recessive conditions.

Patient Signature

Partner Signature

New Patient Questionnaire

Prior Physician History


Yes     No

Yes     No

Infertility     Recurrent Pregnancy Loss     Other

Pregnancy History

Past Pregnancies (include miscarriages and abortions)

Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No

Surgical History (List all prior surgeries in chronological order)

Yes No

Patient Past Medical History

No    Yes
No    Yes
No    Yes
No    Yes
No    Yes
No    Yes
No    Yes
No    Yes
No    Yes
No    Yes
No    Yes
No    Yes
No    Yes
No    Yes
No    Yes
No    Yes
No    Yes
No    Yes
No    Yes
No    Yes
No    Yes
No    Yes
No    Yes
No    Yes
No    Yes
No    Yes
No    Yes
No    Yes
No    Yes
No    Yes

Family History (include Parents, Siblings, Grandparents, Aunts, Uncles and Cousins)

No    Yes
No    Yes
No    Yes
No    Yes
No    Yes
No    Yes
No    Yes
No    Yes
No    Yes
No    Yes
No    Yes

Ancestry

Social History

No    Yes
No    Yes
No    Yes
No    Yes
No    Yes
No    Yes
No    Yes
No    Yes
No    Yes

Current Medications

Allergies (List allergies to medication or environmental allergies)

Menstrual History


Regular    Irregular

Yes    No

GYN Review of Systems

No   Yes
No   Yes
No   Yes
No   Yes
No   Yes
No   Yes
No   Yes
No   Yes
No   Yes

GYN History

No   Yes
No   Yes
No   Yes
No   Yes
No   Yes
No   Yes
No   Yes
No   Yes
No   Yes
No   Yes
No   Yes
No   Yes
No   Yes
No   Yes
No   Yes
No   Yes

Male Partner Information

No   Yes
No   Yes
No   Yes

Review of Systems

No   Yes
No   Yes
No   Yes
No   Yes
No   Yes
No   Yes

Urologic History

No   Yes
No   Yes
No   Yes
No   Yes
No   Yes
No   Yes
No   Yes
No   Yes
No   Yes
No   Yes
No   Yes

Surgical History (List all prior surgeries in chronological order)

Medications (List current medications)

Allergies (List allergies to medication or environmental allergies)

Past Medical History (List illnesses or hospitalizations)

Social History

No    Yes
No    Yes
No    Yes
No    Yes
No    Yes
No    Yes
No    Yes
No    Yes

Male Partner's Family History (include Parents, Siblings, Grandparents, Aunts, Uncles and Cousins)

No    Yes
No    Yes
No    Yes
No    Yes
No    Yes
No    Yes
No    Yes
No    Yes
No    Yes

Ancestry

Testing

No   Yes

Treatment

No   Yes
No   Yes
No   Yes
No   Yes
No   Yes
No   Yes