(850) 857-3733

4400 Bayou Blvd Suite 36, Pensacola, FL 32503

New Patient Application

NewLIFE offers patients assistance from uniquely qualified staff members.

The experience is enhanced by:

  • An Online New Patient Application process
  • Expert assistance with insurance benefits
  • Flexible hours for testing and appointments
  • Efficient use of advanced scheduling for procedures
  • Convenient, easy-access office locations
  • Ample consultation time and honest counseling

INSTRUCTIONS: To request an appointment, please complete the following Fertility Questionnaire. The last section is for the male to complete. You may send it by clicking the “Submit Form” button on the last page. Please look for a reply which will request additional information in order to arrange your first visit. If for any reason you do not receive a reply, please call our office.

*Important: All fields marked with a ( * ) are required. If you have any questions regarding this form, please call us at (850) 857-3733

Fertility Questionnaire New Leaders In Fertility & Endocrinology

Female First Name *

Female Last Name *

Female D.O.B *

Female Age *

Female Current Occupation *

Female Ethnic Background *

Female Current Weight (lbs.) *
Female Current Height (inches) *

Male First Name

Male Last Name

Male D.O.B

Male Age

Male Current Occupation

Male Ethnic Background

Male Current Weight (lbs.)
Male Current Height (inches)


City of Residence *

State of Residence *

Name of OB/GYN physician or provider *

Name of physician making your referral *

How did you first learn about the NewLIFE practice and services? *

The primary reason for this consultation: *

How long have you attempted to conceive, or not use contraception? *
Years

Have you used fertility treatments before this consultation? *  Yes No

If Yes, check types used:

Have you ever been pregnant before? *  Yes No

How many total pregnancies?

Number of live births?

Number of miscarriages?

Number of elective abortions?

Number of ectopic tubal pregnancies?

Menstruation & Ovulation

Are your menstrual periods irregular or unpredictable? *  Yes No

How many days between the beginning of one menstrual period to the beginning of the next? *
Days

How many total days does a typical menstrual period last? *
Days

Do you experience abdominal bloating, PMS or breast tenderness monthly? *
 Yes No

Do you experience hot flashes, particularly at night? *  Yes No

Do you bleed between your regular menstrual periods? *  Yes No

Do you have menstrual cramping? *  Yes No

If Yes, What pain do you experience:

Have you had an endometriosis diagnosis by surgery? *  Yes No

If Yes, When?

Do you have family members with endometriosis? *  Yes No

If Yes, who?

Do you have breast/nipple discharge or fluid? *  Yes No

Have you tested for ovulation? *  Yes No

If Yes, how?

Where (facility) and when (month/year) was your Hysterosalpingogram (also called HSG or dye test) performed? (None - if does not apply)*

Have you had treatment for an abnormal PAP of the cervix with cryo freezing, LEEP or laser treatment? *  Yes No

If Yes, which type and when?

Female Health Information

Constitutional *

If Other, Please Describe

Eyes *

If Other, Please Describe

Ears Nose Throat *

If Other, Please Describe

Endocrine *

If Other, Please Describe

Cardiovascular *

If Other, Please Describe

Respiratory *

If Other, Please Describe

Gastrointestinal *

If Other, Please Describe

Genital/Urinary *

If Other, Please Describe

Hematologic *

If Other, Please Describe

Neurological *

If Other, Please Describe

MusculoSkeletal *

If Other, Please Describe

Psychiatric *

If Other, Please Describe

Past & Present Medical Conditions (check any that apply) *

If Other, Please Describe

List of Past Surgeries

Have you had any past surgeries? *  Yes No

Name of Procedure Date or Age of Surgery Findings and complications

Have you ever had an allergic reaction to any medication? *  Yes No

If Yes, Please Specify:

Drug Name Symptoms associated with drug

List ALL medications and doses currently taken * (Include vitamins, herbs and over-the-counter)

Prior Pregnancies and/or Miscarriages

How many weeks/months along Date: month/year C-section, vaginal or D & C Complications

Current Smokers

Do you currently smoke cigarettes? *  Yes No

If Yes, how long does 1 pack currently last?

What Age did you begin to smoke?

Past Smoking Exposure

Have you smoked cigarettes in the past? *  Yes No

If Yes, how many days did a pack last?

If you are a PAST smoker, at what age did you begin tobacco use?

At what age did you stop tobacco use?

Are you exposed to tobacco smoke by a family member? *  Yes No

Do you use illicit or street drugs? *  Yes No

If Yes, What types:

Have you ever had any of the following infections? *

Family Medical History

Medical Condition Relative Who Has This Condition

Genetic History Questionnaire

Are you OR the father-to-be from any of these ethnic backgrounds? Italian, Greek, Middle Eastern, Spanish, Southern Chinese, Asian Indian, Taiwanese, Filipino, Asian *
 Yes No Not Sure

Do you OR the father-to-be have a family member with thalassemia or other hemoglobin problem? *
 Yes No Not Sure

Are you OR the father-to-be from Jewish, French Canadian, or Cajun background? *
 Yes No Not Sure

Do you OR the father-to-be OR anyone in your families have a history of Tay-Sachs, Cystic Fibrosis, or Canavan? *
 Yes No Not Sure

Do you OR the father-to-be OR anyone in your families have a history of neural tube defect - spina bifida, open spine, anencephaly? *
 Yes No Not Sure

Do you OR the father-to-be OR any family member have a history of a pregnancy or child with Down Syndrome? *
 Yes No Not Sure

Do you OR the father-to-be or anyone in your families have hemophilia or another bleeding disorder? *
 Yes No Not Sure

Are you OR the father-to-be from African-American or Hispanic descent? *
 Yes No Not Sure

Do you OR the father-to-be OR anyone in your families have Sickle Cell Disease? *
 Yes No Not Sure

Do you OR the father-to-be OR anyone in your families have neuromuscular disease or muscular dystrophy? *
 Yes No Not Sure

Do you OR the father-to-be or anyone in your families have Huntingtons disease? *
 Yes No Not Sure

Do you OR the father-to-be or anyone in your families have autism, mental retardation or Fragile X? *
 Yes No Not Sure

Do you OR the father-to-be or anyone in your families have a genetic disorder not listed above? Marfans, Neurofibromatosis, etc? *
 Yes No Not Sure

Do you OR the father-to-be or anyone in your families have birth defect not listed above? blindness, deafness, mental retardation, cerebral palsy? *
 Yes No Not Sure

Male's Health Information

Past & Present Medical Conditions *

If Other, Please Describe:

Do you have family members with any of these conditions *  Yes No

If Yes, Please List those family members:

Have you had any surgical procedures in the past? *  Yes No

If Yes, Please List those procedures:

Have you noticed a decrease in sex drive? *  Yes No

Is intercourse, urination or ejaculation painful? *  Yes No

Do you experience impotence? *  Yes No

If Yes, how often?

Do you notice blood in your urine or semen? *  Yes No

If Yes, how often?

Have you ever had a diagnosis of prostatitis? *  Yes No

If Yes, how when?

Have you had a vasectomy? *  Yes No

If Yes, how when?

Have you had a vasectomy reversal? *  Yes No

If Yes, how when?

Have you had a hernia repair? *  Yes No

If Yes, how when?

Have you had surgery on your testicles, scrotum, prostate or penis? *  Yes No

Have you fathered a pregnancy in THIS relationship? *  Yes No

Have you fathered a pregnancy in ANOTHER relationship? *  Yes No

Have you attempted to conceive unsuccessfully in another relationship? *  Yes No

In what facility/laboratory did you get your most recent Semen Analysis?
(None if does not apply) *

If you had a prior Semen Analysis, was the report: *  Normal Abnormal Not Sure

Do you currently smoke cigarettes? *  Yes No

Do you use illicit drugs or street drugs? *  Yes No

If Yes, what types?

Are you exposed to chemicals or toxins? *  Yes No

If Yes, what types?

List ALL medications and doses currently taken:
(Include vitamins, herbs and over-the-counter) *

Have you ever had any allergic reaction to any medications? *  Yes No

Drug name Symptoms associated with drug

Patient/Partner Demographics, Insurance, and Contact Information

Patient Information Spouse Information
Social Security Number *
First Name *
M.I
Last Name *
Address *
City *
State *
Zipcode *
Home Phone *
Work Phone *
Mobile Phone *
Email Address *
Emergency Contact Name *
Emergency Contact Phone *
Policy Holder 1 *
Insurance Company 1 *
ID#1 *
Group #1 *
Insurance Company Phone 1*
Policy Holder 2 *
Insurance Company 2 *
ID#2 *
Group #2 *
Insurance Company Phone 2*