o Not Applicable o Physician Name Phone ( ) Address o Former Patient/Friend o Web Site o Insurance (Name of U:)UIi1IlI.>C Infertility History Form

Transcription

1 AMERICAN SOCIETY FOR REPRODUCTIVE MEDICINE Infertility History Form FOR OFFICE USE ONLY IMPORTANT: Please complete this form and bring it with you to your scheduled visit. This form was developed by the American Society lor Reproductive Medicine to assist physicians and patients in obtaining a complete infertility history. It consists of three parts: Part I: Contact infonnation Part II: Your medical history Part III: Your spouse/male partner's medical history (if applicable) PART I: CONTACT INFORMATION First Name Middle Initial Last Name IAge_ Date of Birth (MMIDDIYY) Occupation. Home Street Address. City State Zip/Postal Code Country Indicate which number to call or leave messages. o Home Telephone ( 0 Work Telephone ( o Cell Phone ( Are you married? 0 Yes 0 Divorced 0 Spouse/Partner's First Name ~... Middle Initial o Not Applicable Last Name... IAge_ Date of Birth (MM/DDIYY) Occupation Home Street Address City State Zip/Postal Code Country Indicate which number to call or leave messages. o Home Telephone ( 0 Work Telephone ( o Cell Phone ( Who referred you? o Physician Name Phone ( ) Address o Former Patient/Friend o Web Site o Insurance (Name of U:)UIi1IlI.>C Physician Notes (for office use only) Who is your Ob/Gyn? Name Phone ( ) Address Who is your Primary Care Physician? Name Phone ( ) Address - Page 1

2 PART II: FEMALE MEDICAL HISTORY AND INFORMATION Reason for Visit: 0 Infertility Evaluation 0 Insemination o Other.. What are your expectations for this What questions do want answered at this _-- Do you have any personal, ethical, or religious objections to any ofour tests or treatments such as insemination, in vitro fertilization, egg donation, sperm donation, masturbation to collect a semen sample, etc.? DONo How many months have you been having intercourse without using any form ofbirth control? Pregnancy Summary Total Number ofall Pregnancies: Number of Miscarriages (less than 20 weeks): Number of Ectopic/Tubal Pregnancies: Number of Elective Terminations (Abortions): Number of Full Term Deliveries: Of these, how many were live births? How many were stillborn? _ Number ofpremature (less than 37 weeks) Deliveries: Of these, how many were live births? How many were stillbom? _ Any Pregnancies with Birth Defects? 0 Yes explain Date Pregnancy Months to Treatments to Delivery Type/D&CI Current Ended or Delivered Conception Conceive Complications Partner? l Menstrual History Menstrual cycle pattern (check all that apply): 0 Regular periods 0 Irregular periods 0 Spotting before periods periods o Heavy periods 0 Light periods 0 Bleeding between periods Number of days between the start of one period to the start of the next period: ~---J How many days of bleeding do you have? ~---J Dates of the 1st day of your last 2 menstrual periods: Age when you had your first period: years old Age when you first noticed: Breast development: ~ears old Pubic hair: years old Underarm hair: ~ears old How many periods do you have per year? Do you need medication to bring on a period? 0 Yes - what If you do not have periods, at what age did you stop having them? years Do you have severe cramping or pelvic pain with your periods? 0 Yes: _Always _Sometimes Jecently _In the past Did your mother take DES when she was pregnant with you? 0 Yes 0 Don't know Contraceptive History o None 0 Condoms dates of use o Foam or Jelly o Birth control pills - dates ofuse o Injectable contraception (Depo-Provera, Lunelle, etc.) - dates o Skin patch - dates o Tubal sterilization procedure (tubes tied) - date (month/year) I [] Never used birth control pills o IUD - dates of use o Tubes untied - date (month/year) I Sexual History Are you sexually active? 0 Yes Is your partner 0 Male o Female How many times do you have intercourse per week? times per week o None t applicable Have you used over-the-counter ovulation kits to time intercourse? 0 Yes ONo Do you have pain with intercourse? 0 Yes Do you use lubricants (K-Y Jelly, etc.) during intercourse? 0 Yes - what ONo Have you had any of the following sexually transmitted diseases or pelvic infections? 0 Yes (check all that apply) o Chlamydia - date 0 Gonorrhea - date 0 Herpes 0 Genital warts/hpv date o Syphilis date 0 HIVI AIDS date 0 Hepatitis - 0 Other Page 2

3 Pap Smear History When was your last pap smear (month and When was your last abnolmal pap smear? o Normal o Not applicable 0 Abnormal Have you undergone any procedures as a result of an abnormal pap smear? o Yes (check all that apply) o Colposcopy 0 Cryosurgery (Freezing) 0 Laser treatment 0 Conization 0 LEEP procedure Breast Screening History Have you ever had a mammogram? 0 Yes - date Result: 0 normal 0 abnormal explain Do you perform breast self exams? ONo Medical History Are you allergic to any medications? 0 Yes If yes, please list and describe Are you allergic to any foods (peanuts, eggs, etc.)? 0 Yes If yes, please list and describe List any medications you are currently taking, including over-the-counter medicines. Do you take any herbal medicines/vitamins or health food store supplements? 0 Yes If yes, please list _- Do you have any medical problem(s)? 0 Yes (Please list type, dates, and treatments.) Surgical History Have you had any surgeries? 0 Yes (List all surgeries in chronologic order.) Year Reason and Type of Surgery (7), Did you have any problems with anesthesia? 0 Yes (describe / ONo Have you had either of these childhood illnesses? 0 Chickenpox (Varicella) 0 German Measles (Rubella) 0 Don't know Other childhood UE.,''"'''''''~. Vaccinations Chickenpox (Varicella): o Yes (dates DNa o Don't know DYes DYes (dates --> ONo o Don't know DNa o Don't know MMR - Measles, Mumps, and Rubella (German Measles): BCG (Tuberculosis): Hepatitis B: o Yes (dates ) ONo o Don't know Polio: o Yes (dates ) ONo o Don't know Hepatitis A: o Yes (dates ) DNa o Don't know Tetanus: o Yes (dates ) ONo o Don't know Influenza: o Yes (dates ) ONo o Don't know Page 3

4 Social History How many caffeinated beverages (coffee, tea, soda) do you drink per day? o None Do you smoke cigarettes? 0 Yes How many/day? How many o Quit- ONo Do you drink alcohol? 0 Yes If yes, how many drinks per Have you casually used marijuana, cocaine, or any other similar dntg? 0 Yes Il1p.~,..rlhp_... --, Do you exercise? 0 Yes Are you aware of any radiation exposures other than X-rays? 0 Yes Do you feel safe in your own home? 0 Yes Review of Physical Symptoms General: Head, Eyes, Ears, Nose, and Throat: Respiratory: o Recent weight gain or loss o Dizziness 0 Loss of sense of smell o Shortness of breath o Anorexia/Bulimia o Headaches 0 Chronic nasal congestion o Asthma o Bronchitis o Lack of energy o Blurred vision 0 Ringing ears o Pneumonia 0 Tuberculosis o Fever/Chills o Hearing loss/deafness o Bloody cough o o o o None o None o None Endocrine/Hormonal: Breasts: Neurological Problems: o Diabetes 0 Hair loss o Discharge (clear?_ bloody?_ milky?~ o Weakness/Loss of balance o Thyroid gland problems o Lumps 0 Pain 0 Cancer o Seizures/Epilepsy o Rapid weight gain or loss o Abnonnal mammogram o Headaches o Excessive hunger/thirst o Reduction o Migraine headaches o Temperature intolerance o Augmentation/Breast implants o Numbness hot flashes or feeling cold (saline?_ silicone?~ o Memory loss o o o o None o None o None Gastrointestinal: Genito-Urinary: Skin/Extremities: o Nausea/Vomiting 0 Ulcers o Bladder infections o Unexplained rash/inflammation o Hepatitis 0 Diarrhea o Kidney infections o Acne o Blood in your stools 0 Constipation o Vaginal infections o Skin cancer o Irritable Bowel Syndrome o Frequent urination 0 Leaking urine o Bum injury o Change in bowel habits o Blood in the urine o Moles changing in appearance o Colitis (ulcerative or Crohn's) o Herpes o Excess hair growth o o D o None o None o None Musculoskeletal: Hematologic: Cardiovascular: Unusual muscle weakness o Blood clotting disorder/blood clot o Palpitations/Skipped beats o Decreased energy/stamina o Sickle cell Anemia 0 Thrombophlebitis o Chest pain 0 Heart attack Rheumatoid arthritis DEasy bntising o Stroke 0 Murmurs o Lupus Erythematosus Swollen glands/lymph nodes o High blood pressure o Myasthenia gravis o Blood transfusions (datcs!reasons~_... ) Rheumatic fever o o o Mitral valve prolapse (Need antibiotics o None o None before dental procedures? Yes_ No_ o Mental Health Problems: o Depression 0 Anxiety disorder o Schizophrenia o o None o None Page 4

5 Family History Mother Father Brother(s) Sister(s) Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Living DYes age_ DNo Cause of Death/Age at Death Disorders in You/Your Family Self or Relationship to You Birth defects DYes DNo DDon't Know Blood clots DYes DNo DDon't Know Bloom syndrome DYes DNo DDon't Know Bone/Skeletal Defects DYes DNo DDon'! Know Canavan disease DYes DNo DDon't Know Cancer Breast cancer DYes DNo DDon't Know Colon cancer DYes DNo DDon'tKnow Ovarian cancer DYes DNo DDon't Know Other cancer DYes DNo DDon't Know Color Blindness DYes DNo DDon't Know Cystic Fibrosis DYes DNo DDoll'! Know Deafness/Blindness DYes DNo DDon'tKnow Developmental delay DYes DNo DDon't Know Diabetes DYes DNo DDoll't Know Down syndrome DYes DNo DDon't Know Other cj.u omosome defects DYes DNo DDon't Know Dwarfism DYes DNo DDon'! Know Endometriosis DYes DNo DDon'! Know Familial Dysautonia DYes DNo DDon't Know Fanconi Anemia DYes DNo DDon't Know Galactosemia DYes DNo DDon't Know Gaucher disease DYes DNo DDon't Know Hear! defect from birth DYes DNo DDon'! Know Heart disease DYes IJNo DDon't Know Hemochromatosis DYes DNo DDon't Know Hemophilia DYes DNo DDon't Know Infertility DYes DNo DDon't Know Learning problems DYes DNo DDon'tKnow Marfan syndrome DYes DNo DDon't Know Menopause before age 40 DYes DNo DDon't Know Muscular Dystrophy DYes DNo DDon't Know Neural Tube Defects DYes DNo DDoll't Know Neurologic (brain/spine) DYes DNo DDon't Know Niemann-Pick disease DYes IJNo DDon't Know Obesity DYes DNo DDon't Know Polycystic kidney disease DYes DNo DDon't Know Psychiatric problems DYes DNo DDon't Know Sickle Cell Anemia DYes DNo DDon'! Know Tay-Sachs disease DYes DNo DDon'! Know Thalassemia DYes DNo DDon't Know Thyroid problems DYes DNo DDon't Know Tuberculosis DYes DNo DDon't Know High blood pressure DYes DNo DDon't Know Glaucoma DYes DNo DDon't Know High cholesterol DYes DNo DDon't Know Gallstones DYes DNo DDon't Know Hepatitis [JYes DNo DDon't Know o None of the above o Other (Specify What is your Ancestry? o American Indian or Alaskan Native o Asian or Pacific Islander o Black, not of Hispanic Origin o Hispanic o White, not of Hispanic Origin o Other (specify ~ Page 5

6 PRIOR INFERTILITY TESTING AND TREATMENT Have you had prior infertility testing or treatment elsewhere? DYes DNo Prior Tests (check all that apply): D Basal body temperature chart,.. ' D Thyroid test D Ovulation test kit (date /results... ~ D Day 3 blood test for FSH level D Hysterosalpingogram (HSG) (date lresults ) D Laparoscopy surgery D Hysteroscopy surgery (date /results ) [J Progesterone blood test D Prolactin blood test,..._--' Prior Treatment (check all that apply): # of cycles Dates (mo/year) (mohea,) Outcome " From 1 _Pregnant: _Delivered _Ectopic _Miscarriage; _Not Pregnant :.utnhlterme msemmahon: o CIQmiphene citrate with tim!:!;! intercqurse: -- From 1 _Pregnant: _Delivered _Ectopic _Miscarriage;._Not Pregnant maximum # tablets per day? o Clomiphene citrat!: with insemination: maximum # tablets per day? to_l Pregnant: _Delivered _Ectopic _Miscarriage; _Not Pregnant o Dailv fertility dntg injections with inseminatiqn: maximum # vials per day?_ -- From I _Pregnant: _Delivered _Ectopic _Miscarriage; _Not Pregnant o Completed in vitro fertilizatiqn cyele(s): -- L#eggs~ #embryos transfelted_ #frozen _Pregnant: _Delivered _Ectopic _Miscarriage; _Not Pregnant -- 2,#eggs~ #embryos transferred~ #frozen _Pregnant: _Dclivcred._Eetopic _Miscarriage; _Not Pregnant 3. # eggs~ #embryos transferred~ #frozen _Pregnant: _Delivered _Ectopic _Miscarriage; _Not Pregnant - 4.#eggs~ #embryos transferred_ ---..! _Pregnant: _Delivered _Ectopic _Miscarriage; _Not Pregnant o Frozen embdlq transfers: -- I. # embryos transferred Pregnant: _Delivered _Ectopic _Miscarriage; _Not Pregnant 2. # embryos transferred Pregnant: _Delivered _Ectopic _Miscarriage; _Not Pregnant 3. # embryos transferred Pregnant: _Delivered_Ectopic _Miscarriage; _Not Pregnant 4. # embryos transferred Pregnant: _Delivered _Ectopic _Miscarriage; _Not Pregnant Canceled in vitro fertilization attempt(s): -- D An~ other prior treatment (describe): AdditionallnfonnationiComplications: EMOTIONAL STATUS On a scale of 1-10 (10 being the worst), estimate the level of stress you feel due to infertility and other pressures. Do you see a counselor? DYes - For how long?. How often? DNo List any antidepressant/antianxiety medications you are currently taking. Describe any emotional, marital, or sexual problems caused by your infertility. PATIENT'S SIGNATURE DATE I confirm that I have reviewed the information above. PHYSICIAN'S Page 6

7 PART III: MALE MEDICAL HISTORY AND INFORMATION Complete with your male partner if applicable. Have you been evaluated by a urologist? DYes D No Have you previously conceived with another woman? Yes_ D Yes: How many Have you had a semen analysis? DYes D No D No: Birth control used? No Date Volume Count I iviotility Morphology Do you have difficulty with erections? DYes D No Are you able to ejaculate inside your partner's vagina? D DYes D No Do you have retrograde ejaculation of sperm into the bladder? DYes D No Have you had any of the following sexually transmitted diseases or severe testicular pain? D Yes (check all that apply) D No D Chlamydia - date D Gonorrhea - date D Herpes date Genital warts/hpv D Syphilis D HIV/ AIDS - D Hepatitis date Have you had a history of undescended testicles? DYes - One Both D No Have you ever had torsion/twisting of the testicles? DYes D No Did you have mumps after puberty? DYes D No Have you had injury to your testicles requiring an ER visit or hospitalization? DYes D No Have you been diagnosed with any of the following diseases? D Diabetes Mellitus Yes_No D Cancer - Yes_No D Multiple Sclerosis - Yes_No_ D Other neurologic problems Yes No D Prostatic infections - Yes_No D Urinary infections Yes No_ D High Blood Pressure - Yes_No_ If yes, any medications? Have you had fever (> lop F) in the last 3 months? DYes D No Have you had a vasectomy? DYes (date ) D No If yes, have you had a vasectomy reversal? D Yes (date~ D No Have you had varicocele surgery? DYes D No Have you had hernia surgery? DYes D No Have you had other surgery to the scrotum or groin area? DYes D No Are you exposed to prolonged heat in the workplace? DYes D No Are you exposed to any radiation or harmful chemicals in the workplace? DYes Have you had chemotherapy or radiation for cancer? DYes D No Are you allergic to any medications? DYes D No If yes, please list and describe D No List your current me~dj(~atl List any current medical How many caffeinated beverages do you drink per D None Do you smoke cigarettes? D Yes How many/day? How many years? D Quit- DNo Do you drink alcohol? DYes D No If yes, how many drinks per Have you casually used marijuana, cocaine, or any other similar drug? DYes (de:scllb<: ) DNo Do you use herbal medicines/vitamins or health food store supplements? DYes DNo ~ Are you aware of any solvents/toxic materials exposure? DYes D No Do you use hot tubs regularly? DYes D No Did your mother take DES during pregnancy to prevent miscarriage? DYes D No D Don't know Have any of your immediate family members had difficulty conceiving a child? DYes DNo If yes, please des,crilbe Page 7

8 Family History Mother Father Brother(s) Sister(s) Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather Living DVes age_ DNo DVes age_ DNo DVes age_ DNo DVes-age_ DNo DVes- age_ DNo Calise of Death/Age at Death What is your Ancestry? o Amelican Indian or Alaskan Native o Asian or Pacific Islander o Black, not of Hispanic Origin o Hispanic o White, not of Hispanic Origin o Other Disorders in Your Family Relationshi12 to Vou Bloom syndrome DVes DNo DDon't Know Bone/Skeletal Defects DVes DNo DDon't Know Canavan disease DVes DNo DDon't Know Color Blindness DVes DNo DDon't Know Cystic Fibrosis DVes DNo DDon't Know Deafness/Blindness DVes DNo DDon't Know Developmental delay DVes DNo DDon't Know Down syndrome DVes DNo DDon't Know Other chromosome defects DVes DNo DDon't Know Dwarfism DVes DNo DDon't Know Familial Dysautonia DVes DNo DDon't Know Fanconi Anemia DVes DNo DDon't Know Galactosemia DVes DNo DDon't Know Gaucher disease DVes DNo DDon't Know Heart defect from birth DVes DNo DDon't Know Hemochromatosis DVes DNo DDoll't Know Hemophilia DVes DNo DDon't Know Learning problems DVes DNo DDon't Know Marfan syndrome DVes DNo DDon't Know Muscular Dystrophy DVes DNo DDoll't Know Neural Tube Defects DVes DNo DDon't Know Neurologic (brain/spine) DVes DNo DDon't Know Niemann-Pick disease DVes DNo DDon't Know Polycystic kidney disease DVes DNo DDon't Know Sickle Cell Anemia DVes DNo DDon't Know Tay-Sachs disease DVes DNo DDon't Know Thalassemia DVes DNo DDon't Know High blood pressure DVes DNo DDon't Know Glaucoma DVes DNo DDoll't Know High cholesterol DVes DNo DDon't Know Gallstones DVes DNo DDon't Know Hepatitis DVes DNo DDon't Know o None of the above o Other (Specify SPOUSE/MALE PARTNER'S SIGNATURE DATE I confirm that I have reviewed the information above. PHYSICIAN'S SIGNATURE. DATE, Page 8