New Intended Parent Medical Questionnaire

Fill out the form below to take the first steps towards your new family

Personal Details

Donor Number

Surrogate Number

Given Name

Middle Initial

Family Name

Date of Birth

Age

City

State

Zip Code

Day Phone

Evening Phone

Mobile Phone

Relationship Status

Primary Language

Sexual Orientation

I have an American Passport:

Passport Valid Until

How did you hear of us?

Program Details

Service Type

Select a Program

Sperm Source

I Will Provide

I Have Frozen Embryos

Donor Preference

Physical Details

Height

Weight

Hair Color

Eye Color

Skin Color

Blood Type

Rh Factor

Medical Details

Have you had a Hysteroscopy in the last 6 months

What is the medical diagnosis for needing donor assisted IVF?

Have you undergone IVF in the past?

How many IVF self-cycles did you have?

Have you ever had hyper-stimulation?

Do you have children?

Have you ever had a miscarriage?

Have you ever had any reproductive tract infections?

Have you ever had reproductive surgery?

Are you allergic to anesthetic agents?

Have you ever had your embryos screened for genetic disorders (PGS)?

Do you, your partner or a family member have any hereditary disorders?

Have you ever been treated for HIV, Hepatitis B, Hepatitis C or Syphilis?

Have you ever had a Hepatitis B vaccination?

Do you have a normal menstrual cycle?

When was the date of your last menstrual cycle?

Do you smoke?

Partners Details

Given Name

Middle Initial

Family Name

Date of Birth

Age

Day Phone

Evening Phone

Mobile Phone

Primary Language

I have an American Passport:

Passport Valid Until

Are you a known Genetic Mutation Carrier?

Partner Physical Details

Height

Weight

Hair Color

Eye Color

Skin Color

Blood Type

Rh Factor

Partner Medical Details

Have you had a semen analysis in the last 3 to 6 months?

Have you ever used oral medication to improve sperm quality?

Have you ever had a reproductive surgery?

Have you ever been treated for HIV, Hepatitis B, Hepatitis C or Syphilis?

Have you ever had a Hepatitis B vaccination?

Have you been tested for hormonal imbalances?

Have you ever used illegal substances?

Do you use prescription medication?

How often do you drink alcohol?

Do you smoke?

Donor Attributes

Height

Eye Color

Hair Color

Hair Type

Additional Information

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If there is anything else about your medical history that may be pertinent that is not included in this questionnaire, please provide this information here.

BetaPlus is committed to providing the highest level of care, confidentiality, courtesy, and results to every Intended Parent. We are committed to providing a stress free enivorment and programs to allow you to focus on yourself. If you have any questions regarding this questionnaire, contact us and we will be more than happy assist you.

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New Intended Parent Medical Questionnaire

Personal Details

Program Details

Physical Details

Medical Details

Partners Details

Partner Physical Details

Partner Medical Details

Donor Attributes

Additional Information

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