Patient registration

Patients information

Patient 1

First Name

Last Name

Patient 1 Sex*

Patient 1 DOB

Patient 1 Phone*

Which phone number is this?*

Patient 1 Email*

Address*

Patient 1 Social Security #*

City*

State/Province

ZIP / Postal

Patient 1 occupation

Patient 2

First Name

Last Name

Patient 2 Sex*

Patient 2 DOB

Patient 2 Phone*

Which phone number is this?*

Patient 2 Email*

Address*

Patient 2 Social Security #*

City*

State/Province

ZIP / Postal

Patient 2 occupation

Donor

Using an Egg Donor Using a Sperm Donor

Have you had any prior fertility treatment? (ex. IUI, IVF, etc.)

Yes No

Have you had any prior IVF cycles with PGT?

Yes No

If applicable, please elaborate on any previous fertility treatment and experiences.

Patient 1's Family

Patient 1

My general health is:*

ExcellentGoodFairPoor

Health problems

Patient 1's father

AliveDeceased

[group group-alive-f-p1 clear_on_hide]

Current age*

[/group]

[group group-death-f-p1 clear_on_hide]

Age at death*

Cause of death*

[/group] [group group-alive2-f-p1 clear_on_hide]

My father's general health is:*

ExcellentGoodFairPoor

Health problems

[/group]

Patient 1's mother

AliveDeceased

[group group-alive-m-p1 clear_on_hide]

Current age*

[/group]

[group group-death-m-p1 clear_on_hide]

Age at death*

Cause of death*

[/group] [group group-alive2-m-p1 clear_on_hide]

My father's general health is:*

ExcellentGoodFairPoor

Health problems

[/group]

Patient 1's Siblings

Number of brothers*

[group group-brothers-p1 clear_on_hide]

Age(s)

[/group]

Number of sisters*

[group group-sisters-p1 clear_on_hide]

Age(s)

[/group]

[group group-b-s-p1 clear_on_hide]

Health problems for siblings:

Do your siblings have any children?*

YesNo

[/group] [group group-s-c-p1 clear_on_hide]

Health problems in sibling's children:

[/group]

What is your ethnic background/ancestry?*

Do you have any Jewish ancestry?*

YesNo

Are you Ashkenazi Jewish ?

YesNo

Patient 2's Family

Patient 2

My general health is:*

ExcellentGoodFairPoor

Health problems

Patient 2's father

AliveDeceased

[group group-alive-f-p2 clear_on_hide]

Current age*

[/group]

[group group-death-f-p2 clear_on_hide]

Age at death*

Cause of death*

[/group] [group group-alive2-f-p2 clear_on_hide]

My father's general health is:*

ExcellentGoodGoodPoor

Health problems

[/group]

Patient 2's mother

AliveDeceased

[group group-alive-m-p2 clear_on_hide]

Current age*

[/group]

[group group-death-m-p2 clear_on_hide]

Age at death*

Cause of death*

[/group] [group group-alive2-m-p2 clear_on_hide]

My mother's general health is:*

ExcellentGoodGoodPoor

Health problems

[/group]

Patient 2's Siblings

Number of brothers*

[group group-brothers-p2 clear_on_hide]

Age(s)

[/group]

Number of sisters*

[group group-sisters-p2 clear_on_hide]

Age(s)

[/group]

[group group-b-s-p2 clear_on_hide]

Health problems for siblings:

Do your siblings have any children?*

YesNo

[/group] [group group-s-c-p2 clear_on_hide]

Health problems in sibling's children:

[/group]

What is your ethnic background/ancestry?*

Do you have any Jewish ancestry?*

YesNo

Are you Ashkenazi Jewish ?

YesNo

Family History

Please answer for both patients' sides of the family.

Have you or any blood relatives had any of the following (including grandparents, aunts and uncles, and cousins, but excluding relative by marriage)? If "Yes", please indicate which family member(s) and provide details.

Consanguinity

Is there a blood relation between Patient 1 and Patient 2 (i.e. consanguinity, for example cousins or otherwise related?*

YesNo

[group group-blood-relation clear_on_hide]

If yes, please describe the relation:

[/group]

Patient 1

Multiple miscarriages (3 or more)*

YesNoI don't know

[group group-miscarriages-p1 clear_on_hide]

Family member(s) and details*

[/group]

Still birth*

YesNoI don't know

[group group-miscarriages-still-birth-p1 clear_on_hide]

Family member(s) and details*

[/group]

Early death (under age 50)*

YesNoI don't know

[group group-early_death-p1 clear_on_hide]

Family member(s) and details*

[/group]

Birth defects*

YesNoI don't know

[group group-birth_defects-p1 clear_on_hide]

Family member(s) and details*

[/group]

Intellectual disabilities or mental retardation*

YesNoI don't know

[group group-disabilities-p1 clear_on_hide]

Family member(s) and details*

[/group]

Cancer under age 50*

YesNoI don't know

[group group-cancer_u50-p1 clear_on_hide]

Family member(s) and details*

[/group]

Comments/Other

Patient 2

Multiple miscarriages (3 or more)*

YesNoI don't know

[group group-miscarriages-p2 clear_on_hide]

Family member(s) and details*

[/group]

Still birth*

YesNoI don't know

[group group-miscarriages-still-birth-p2 clear_on_hide]

Family member(s) and details*

[/group]

Early death (under age 50)*

YesNoI don't know

[group group-early_death-p2 clear_on_hide]

Family member(s) and details*

[/group]

Birth defects*

YesNoI don't know

[group group-birth_defects-p2 clear_on_hide]

Family member(s) and details*

[/group]

Intellectual disabilities or mental retardation*

YesNoI don't know

[group group-disabilities-p2 clear_on_hide]

Family member(s) and details*

[/group]

Cancer under age 50*

YesNoI don't know

[group group-cancer_u50-p2 clear_on_hide]

Family member(s) and details*

[/group]

Comments/Other

Carrier Screening

Have either you or your partner had universal carrier screening or carrier screeing performed for common genetic conditions, such as cystic fibrosis, spinal muscular atrophy (SMA), or Fragile X syndrome? If "Yes" please provide reports using the upload link. Alternatively, you may fax reports to 847-400-1516.

Patient registartion

Patients information

Patient 1

Patient 2

Donor

Have you had any prior fertility treatment? (ex. IUI, IVF, etc.)

Have you had any prior IVF cycles with PGT?

Pregnancy History

What were the outcomes of each of these pregnancies?

Current partner?*

Current partner?*

Current partner?*

Current partner?*

Current partner?*

Patient 1's Family

Patient 1

My general health is:*

Patient 1's father

My father's general health is:*

Patient 1's mother

My father's general health is:*

Patient 1's Siblings

Do your siblings have any children?*

Do you have any Jewish ancestry?*

Are you Ashkenazi Jewish ?

Patient 2's Family

Patient 2

My general health is:*

Patient 2's father

My father's general health is:*

Patient 2's mother

My mother's general health is:*

Patient 2's Siblings

Do your siblings have any children?*

Do you have any Jewish ancestry?*

Are you Ashkenazi Jewish ?

Family History

Please answer for both patients' sides of the family.

Consanguinity

Is there a blood relation between Patient 1 and Patient 2 (i.e. consanguinity, for example cousins or otherwise related?*

Patient 1

Multiple miscarriages (3 or more)*

Still birth*

Early death (under age 50)*

Birth defects*

Intellectual disabilities or mental retardation*

Cancer under age 50*

Patient 2

Multiple miscarriages (3 or more)*

Still birth*

Early death (under age 50)*

Birth defects*

Intellectual disabilities or mental retardation*

Cancer under age 50*

Carrier Screening

Patient 1

Universal carrier screening*

Cystic fibrosis*

Fragile X syndrome*

Spinal muscular atrophy (SMA)*

Patient 2

Universal carrier screening*

Cystic fibrosis*

Fragile X syndrome*

Spinal muscular atrophy (SMA)*