FALL 2019 and Spring 2020- Medical Forms for the Cade Foundation Family Building Grant
Please share this link with your doctors office AFTER you have completed and submitted Part I of your application.


Completed forms are due by 2/1 or 7/1 deadlines.​
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Tinina Q Cade Foundation Family Building Grant Physician's Medical Form
Tinina Q Cade Foundation Family Building Grant Medical Form Questionaire
1) Physicians Name *
2) Clinic Name and Address *
3) Phone Number of Clinic *
4) Patients Name (s) *
5) Contact at Clinic (if we have any questions) *
Email Address of the person completing form *
6) Seeking grant for fertility treatment for the following: (check all that apply): *
Required
7) Female Medical History (for applicants applying for a grant for fertility treatment only; Scroll down to Male Questions if applicant is a male)
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Age
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Patient BMI
Does this patient have infertility?
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Length of time attempting to conceive?
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Cause of infertility
Number of Gynecologic Surgeries in the past
History of endometriosis
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History of fibroids
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Has this patient ever been treated for cancer?
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Obstetrical History  (G/P/A/L)
HSG Results
Laparoscopy
Hysteroscopy Results
Other gynecological surgery
Ultrasound Results
Hormone Testing:
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Day #3 FSH
Estradiol
AMH
Clomid treatments: Number of cycles
Number of IVF cycles
Number of IUI Cycles
Male Medical History (for applicants seeking grants for fertility treatment only)
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Does this patient have infertility?
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Length of time of currently attempting to conceive
Cause of infertility
Age
Medical Problems
Surgical History
Date of Sperm Analysis
MM
/
DD
/
YYYY
Sperm Count
Sperm Motility
Sperm Morphology
Current Medications
Has this patient ever been treated for cancer?
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Thank you for completing this form for your patient.  
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