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Application Form

SECTION A (General BabyHope membership application)
DATE :
How did you hear about the BabyHope?
CONTACT INFORMATION
Thank you for your interest in the BabyHope, your home for infertility information and more. Application material will be kept confidential and reviewed only by the BabyHope Committee.
Full Name :
Address :
City, State Zip :
Home Phone :
Mobile Phone :
Email Address :
Date of Birth: (MM/DD/YYYY)
Gender :
Marital Status :
If married, how long? Yrs
Spouse's name
Spouse's occupation
Name and phone number of your fertility clinic and/or doctor:
Have you undergone In Vitro Fertilization Treatment before?
What do you expect to get from BabyHope?
Other :
Does your insurance cover infertility treatments?
Do you currently have any children?
SECTION B: (For members interested on fundraisers only)
MEDICAL HISTORY FOR WOMEN
Height
Weight
Body Mass Index
Length of time of currently attempting pregnancy
Gynecological History
Age of first period
Average length of menstrual cycle
History of surgery:
History of endometriosis :
History of pelvic infections
Obstetrical History
Number of Pregnancies
Year Full term
Preterm Miscarriage
Terminations
Previous Infertility Testing
HSG results:
Laparoscopy
Hysteroscopy
other gynecological surgery
Ultrasound results
Do you have fibroids?
Do you have endometriosis?
If yes, which stage?
Previous Fertility Treatments
Procedure/Date
Out of Pocket Cost to You
Amount Covered by Insurance
Medical Problems
Surgical History
Do you smoke?
What prescription/over the counter drugs do you take?
Have you used marijuana or other illegal drugs?
If yes, please detail which drugs and your frequency of use.
Significant Family Medical History
Please detail any other important health and/or medical information you think the committee should know:
 
MEDICAL HISTORY FOR MEN
Height
Weight
Body Mass Index
Length of time of trying to conceive
Have you had any significant medical problems?
Please detail your surgical history
Have you had any urological problems?
Have you seen a urologists?
If yes, please write the urologist's name and phone number below
Have you ever fathered a pregnancy?
If yes, when?
Was the child carried to full term?
Have you been told that you have male infertility?
If yes, what is/was the issue?
Sperm Analysis
Date Count Motility Morphology. Have you ever been treated for cancer?
If yes, what medications/treatments?
Medical Problems
Surgical History
Do you smoke?
What prescription/over the counter drugs do you take?
Have you used marijuana or other illegal drugs?
If yes, please detail which drugs and your frequency of use.
Significant Family Medical History
Please detail any other important health and/or medical information you think the committee should know:


DISCLAIMER
By signing below, I authorize the BabyHope Selection Committee to obtain information, written, oral, or other, from my physician and any law enforcement agency, consumer reporting agency, or other persons with knowledge of such information, bearing on my character, general reputation, personal characteristics, mode of living, criminal background and driving record.  BabyHope reserves the right to conduct this investigation at any time.
I am aware that my name, address, telephone number, and e-mail address will be distributed to the BabyHope board after the grant has been awarded. I understand that only my contact information will be available to board member, and all other information contained in the application materials will remain confidential, reviewed only by members of the selection committee.
The information I have given is correct and you may verify the information listed if necessary. I understand that selection is at the discretion of the BabyHope Selection Committee and will not seek compensation of any sort in regards to the decision of the final awardees or the selection process/criterion.

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