IDENTIFYING INFORMATION

Transcription

1 PATIENT LABEL FEMALE QUESTIONNAIRE Please answer the questions to the best of your ability. Leave blank any questions to which you do not know the answer. If you are uncomfortable with any questions, you may leave them blank. IDENTIFYING INFORMATION Date questionnaire completed: Name: Phone Number: Address: Current Age: Date of Birth: Height: Weight: Partner s Name: Partner s Date of Birth: Married Unmarried Separated Divorced Going through divorce FERTILITY HISTORY 1. Why are you coming to see us? 2. How long have you and your partner been attempting pregnancy? 3. Have you ever gotten pregnant with a different partner? Yes No 4. Have you ever tried to get pregnant with a different partner? Yes No 5. Have you been treated for infertility previously? Yes No If yes, what was the cause of the infertility? PREGNANCY HISTORY Have you even been pregnant? Yes No Date Outcome How long to conceive? Infertility therapy? Complications with pregnancy? Is current partner the biological father? GYNECOLOGICAL HISTORY 1. How old were you when you had your first period? How frequently do your periods come? Every days. 2. Do you have blood clots with your periods? Yes No How long do your periods last? days. When did your last period start? 3. Do you experience cramping with your period? Yes No 4. How would you describe the cramps? Mild Moderate Severe 5. Do you have pelvic pain and, if so, give details? Yes No When? Describe _ 6. Do you bleed or spot between periods? Yes No If yes, please describe 1

2 7. Do you have pain during urination? Yes No 8. Do you have pain with bowel movements? Yes No 9. Do you have pain during or after intercourse? Yes No 10. When was your last Pap smear? Was it normal? Yes No 11. Have you ever had an abnormal Pap smear result? Yes No If yes, what therapy was performed? Repeat Pap smear Antibiotics Colposcopy (microscope evaluation) Biopsy Cryotherapy (freezing of cervix) Laser therapy Cone biopsy Loop excision (LEEP) Other 12. Have you ever had any of the following infections involving any part of the reproductive tract (vagina, cervix, uterus, fallopian tubes, ovaries)? Check all that apply: Yeast Trichomonas Gonorrhea Chlamydia Genital warts Herpes Syphilis Other How many times, in total, have you been treated for these infections? 13. Have you ever had a mammogram? Yes No If yes, when? Result? Normal Abnormal 14. Have you ever been diagnosed with (check all that apply): Uterine abnormality Uterine fibroids or myomas Endometriosis Ovarian cysts PAST MEDICAL HISTORY Have you ever been diagnosed with (check all that apply): Acne Anemia Appendicitis Arthritis Autoimmune disease (eg. Lupus, rheumatoid arthritis) Blood transfusion Breast (nipple) discharge Breast disease Chronic bronchitis Cancer (Specify) Colitis Diabetes Dizziness Gallbladder disease Hair loss Heat/cold intolerance Heart disease Hepatitis Hirsutism (excess hair growth) High blood pressure Hot flashes Kidney problems Liver problems Loss of balance Measles: German Genetic disease Mumps Neurological Problems Poor sense of smell Rheumatic fever Scarlet fever Seizures Thyroid problems Tuberculosis Ulcers Vision problems How many times have you been hospitalized for these conditions? List dates: PAST SURGICAL HISTORY Have you ever had any surgeries? Yes No If yes, please indicate date, type, findings at surgery, treatment performed, and any complications. 2

3 PREVIOUS TESTS Have you ever had any of the following tests performed? Basal body temperature Hormonal tests Hysterosalpingogram (x-ray dye test) Ovulation predictor kit Endometrial biopsy Ultrasound Sonohysterogram (SHG) Infection test (gonorrhea, chlamydia) Genetic tests Other tests PREVIOUS TREATMENTS Have you ever taken any of the following medications listed below? Yes No If yes, check all that apply: Clomiphene citrate (Clomid, Serophene): Dose # of cycles Letrozole (Femera): Dose # of cycles hcg (Ovidrel, Novarel, Profasi) Progesterone (injections, Crinone, Endometrin, Prometrium) Progestins (Provera) Estrogens (Estrace, Vivelle) Metformin (Glucophage) Injectable gonadotropins (Gonal-F, Follistim, Bravelle, Menopur) Bromocriptine (Parlodel) GnRH agonist (Lupron, Synarel, Zoladax) Cabergoline (Dostinex) GnRH antagonist (Ganirelix, Cetrotide) Heparin / Lovenox Steroids (Medrol, Prednisone, Dexamethasone) Other 2. Have you ever had intrauterine inseminations? Yes No If yes, specimen was provided by (check all that apply) Partner Donor 3. Have you ever attempted in vitro fertilization? Yes No If yes, please specify below (if known) Date Location FSH Dose (vials or IU/day) # Eggs retrieved ICSI (Y/N) # Eggs fertilized # Embryos transferred Pregnant Y/N Outcome FAMILY HISTORY Have any of these illnesses occurred in your family? Check all that apply and indicate family relationship of persons to you: Illness Relationship Illness Relationship to you High blood pressure Ovarian cancer Diabetes Colon cancer Heart disease Other Breast cancer SOCIAL HISTORY 1. Do you drink alcohol? Yes No If yes, how many drinks per week? 2. Do you smoke? Yes No If yes, how many packs per day? 3. Do you use illicit (illegal) drugs? Yes No If yes, please list 4. Do you exercise regularly? Yes No If yes, please indicate type of exercise and estimate hrs/week spent in this activity: Type Hours/week Type Hours/week 3

4 5. Have you had significant weight change in the last year? Yes No If yes, please indicate: Weight gain lbs Weight loss lbs 6. Do you follow a particular food diet? Yes No If yes, please indicate: 7. Do you take any special food supplements or herbal medicines? Yes No If yes, please list: MEDICATIONS 1. Are you allergic to any medications? Yes No If yes, please indicate name of medication and type of reaction it causes. Reaction 2. Are you currently taking any prescription medications? Yes No If yes, please indicate below Reason 3. Are you currently taking any over-the-counter medications? Yes No If yes, please indicate below Reason REVIEW OF SYSTEMS Do you presently have any problems or symptoms in the following areas? Circle YES or NO below. If YES, please give explanation. Constitutional (good general health lately) Yes No Eyes Yes No Ear/Nose/Mouth/Throat Yes No Cardiovascular (heart/blood vessels/circulation Yes No Gastrointestinal (stomach/intestines) Yes No Genitourinary (genitals/sexual function/kidney/bladder) Yes No Neurological (brain/nervous system} Yes No Integumentary (skin areas) Yes No Psychiatric (emotions/mood/memory) Yes No Musculoskeletal (bones/joints/muscles) Yes No Endocrine (hormones/metabolism/thyroid) Yes No Allergic/immunological (allergies/immune system) Yes No Patient Comments Physicians Comments EMPLOYMENT Describe all recent employment (last 5 years) including job title, description of responsibilities, and duration of employment. _ 4

5 PRECONCEPTION GENETIC SCREENING QUESTIONNAIRE Do you or anyone in your family have (or did a deceased person have) any of the following disorders? (Please circle) 1. Down Syndrome Yes No Not sure 2. Other chromosome abnormalities (translocations, trisomies, deletions) Yes No Not sure 3. Neural tube defects: Spina bifida (open spine), anencephaly (open skull) Yes No Not sure 4. Huntington s disease/chorea Yes No Not sure 5. Hemophilia/bleeding disorders Yes No Not sure 6. Muscular dystrophy Yes No Not sure 7. Cystic Fibrosis Yes No Not sure If yes, indicate the relationship of the affected person to you: 8. Were you born with a congenital birth defect? Yes No Not sure If yes, what type of birth defect is present? 9. Have you had any children born alive or dead with any birth defect not listed above? Yes No Not sure If yes, what was the defect and who was affected? 10. Do you have any relatives with intellectual and/or developmental disabilities? Yes No Not sure If yes, indicate the relationship of the affected person to you: Indicate the cause if known: 11. Do you have any children or relatives diagnosed with Autism? Yes No Not sure If yes, indicate the relationship of the affected person: 12. Do you or anyone in your family have a birth defect, familial disorder, or a chromosome abnormality not listed above? Yes No Not sure If yes, indicate the condition and the relationship of the affected person to you: 13. Have you had 2 or more first trimester pregnancy losses or a stillborn child? Yes No Not sure 14. Have you had a chromosome (karyotype) analysis performed? Yes No Not sure If yes, please indicate where it was performed and the results: _ 15. Are you of Jewish ancestry? Yes No Not sure If yes, have you been screened for Tay Sachs Disease? Please indicate the results: 16. Are you of African American ancestry? Yes No Not sure If yes, have you been screened for sickle cell trait? Please indicate the results: 17. Are you of Italian, Greek, Mediterranean or Asian Ancestry? Yes No Not sure If yes, have you been screened for Thalassemia? Please indicate the results: 18. Have you been taking vitamins or folic acid during the last 6 months? Yes No Not sure If yes, what vitamins? How long? 19. Have you been taking iron or calcium supplements during the last 6 months? Yes No Not sure Form completed by (Please print) 5 Relationship to patient (Write self if you are the patient)