Pre-Consultation Questionnaire
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1 Pre-Consultation Questionnaire Patient Date Partner (if applicable) How did you hear about Dr Nick Lolatgis? Couple Reproductive History Years married Length of time trying to get pregnant Birth control previously used (please check all that apply) Pill IUD Condom Vasectomy/Tubal ligation Other When (years) to For how long? Problems with method of contraceptio Previous marriages? Husband Wife Number of pregnancies from previous marriage (wife) Outcome Length of time to get pregnant Number of pregnancies from previous marriage (husband) Outcome Length of time to initiate a pregnancy Female Profile Age Allergies Age at first menstrual period Date of last menstrual period Do you have regular periods? Interval between menses (Day 1 of previous cycle to Day 1 of following cycle) Bleeding between periods? Describe Blood flow during periods: Heavy Moderate Light Number of days Clots? Average number of pads/tampons per day Pain with periods? If yes, describe Do you have any bladder (urinary or bowel ) symptoms with periods, e.g., blood in urine, pain with defecation? If yes, describe Do you have cyclical mood changes related to your menses? If yes, describe Nipple discharge (blood, milk, one or both breasts, pain)? If yes, describe Past Treatments Have you previously been treated by a gynecologist? Describe in detail (pelvic infection, endometriosis, surgery, ovarian cyst) Last Pap Smear rmal Abnormal If abnormal, treatment Have you ever had a mammogram? When (most recent) Dr Nick Lolatgis Pre-Consultation Questionnaire 1 of 6
2 Female Overall General Health Exercise Psychological Family History Habits General Health: Excellent Fair Poor Do you have or have you ever had the following? (please check all that apply) Scarlet fever Rheumatic fever Tuberculosis Hepatitis Syphilis Gonorrhea Pelvic infection Chlamydia Herpes Chronic bronchitis Measles: regular Measles: German Chicken Pox Pneumonia Kidney infection Heart disease Hirsutism, acne High blood pressure Gallbladder problems Liver problems Ulcers Appendicitis Colitis Diabetes Anemia Arthritis Thyroid problems Breast tenderness Breast soreness Breast discharge Neurological problems Seizures Epilepsy Visual disturbance Poor sense of smell Dizziness Loss of balance Chronic headaches Blood transfusions Vaginitis (trichomaniasis, yeast) # of episodes ngonoccal urethritis Parasitic infection Immunization: German measles Endometriosis Ovarian cysts Cancer (specify) Please list the forms and frequency of regular exercises (swimming, cycling, runing, etc.) and give the age you began Exercise Average hrs/week Age Exercise Average hrs/week Age Exercise Average hrs/week Age Have you previously undergone psychological treatment? If yes, please specify when and nature of treatment Mother: Living or deceased? Age Health of Mother Father: Living or deceased? Age Health of Father Number of Siblings Family history of the following (please check all that apply): Infertility Hypertension Cancer Diabetes Thyroid disease Breast Cancer History of AIDS Hepatitis Other Coffee (cups per day) Cigarettes (packs per day) Alcohol (drinks per day) Marijuana Other Has your weight changed significantly in the past 2 years? If yes, describe Do you have what you would consider to be an eating disorder? If so, which ones (please check all that apply): Binges Compulsive craving Purging Dr Nick Lolatgis Pre-Consultation Questionnaire 2 of 6
3 Female History of Fertility Therapy Have you been treated for infertility before? If yes, who was your physician? What cause of infertility was diagnosed? Medications have you taken for infertility (please check all that apply): Clomiphene citrate (Seropene, Clomid) Menopur Estrogens Repronex Antibiotics Progesterone Bromocriptine (Parlodel ) hcg Bravelle Danazol (Danocrine ) Follistim ne Gonal F Other (specify) Which of the following tests have you had performed? BBT Post-coital test Hormonal assays When Results When Results When Results (FSH,LH, prolactin, DHEA-S, testosterone, progesterone) Endometrial biopsy Hysterosalpingogram Ultrasound Antibodies Laparoscopy, hysteroscopy Mycoplasma/Chlamydia Thyroid tests Other (please specify) Have you ever had surgery for tubal reversal? If yes, specify date and surgeon Have you ever had surgery for lysis of adhesions? Have you ever had cervical conization or cautery? Have you ever undergone artificial insemination? If yes, how many cycles? When? Were you exposed to DES (or any other hormones) before birth? Obstetrical History Year Duration of Sex Weight Complications Gestation 1) 2) 3) 4) Dr Nick Lolatgis Pre-Consultation Questionnaire 3 of 6
4 Male Profile Genitourinary Diseases Psychological Age Allergies General Health: Excellent Fair Poor Previous male evaluation for infertility? If yes, when Doctor Are you now under treatment or have you previously been treated with Clomid, steroids, antibiotics, thyroid replacement or hcg? If yes, please give details v Surgical treatment (please give date): Varicocele Biopsy Microsurgery Other Testicular descent: Did your testes descend normally as a child? Did you go through puberty at the same time as your peers? Venereal Disease? Exposure to chemicals? Genitourinary infections (please check all that apply) nspecific urethritis Gonorrhea Excessive exposure to heat Mumps? Fever/Viral infections in the previous 3 months (e.g., influenza) Trauma to testicles? Other Past surgery for any disease Past diseases. Please list any disease(s) from which you now suffer or have received treatment in the past Have you previously undergone psychological treatment? If yes, please specify when and nature of treatment Family History Mother: Living or deceased? Age Health of Mother Father: Living or deceased? Age Health of Father Number of Siblings Family history of the following (please check all that apply): Infertility Hypertension Cancer Diabetes Thyroid disease Breast Cancer History of AIDS Hepatitis Other Habits Coffee (cups per day) Cigarettes (packs per day) Alcohol (drinks per day) Marijuana Other Dr Nick Lolatgis Pre-Consultation Questionnaire 4 of 6
5 Both Partners Sexual History Rate of sexual desire/interest Average frequency of intercourse (per week) Lubrication used (if any) Pain (describe) Do you douche before or after intercourse? Difficulties with reaction and/or ejaculation? If yes, please describe Has there been (or do you anticipate) any difficulty collecting semen samples for evaluation or insemination procedures? Has infertility affected your sexual responsiveness? Genetic Screening Questionnaire 1. Will the female partner be age 35 or older when you have children? 2. Have you or your partner (or anyone in either of your families) ever had: a. Neural tube defects - spina bifida ancelphaly b. Cystic Fibrosis c. Down Syndrome d. Tay Sachs e. Gaucher s f. Canavan s g. Thalassemia h. Sickle Cell Anemia i. Muscular Dystrophy j. Multiple Sclerosis k. Huntington s Disease l. Lou Gehrig s (ALS) m. Parkinsons Disease n. Alcoholism o. Mental retardation/fragile X p. Hemophilia q. Baby with birth defects (explain) r. Cleft Lip/Palate s. Adult Polycystic Renal Disease t. Cancer 3. Have you or your partner had a child stillborn? If yes, describe 4. Do you or your partner (or any close relatives) have any inherited genetic or chromosomal disease, mental retardation and/or birth defects not listed above? If yes, describe Have you ever received counseling for this? 5. Do you or your partner have any close relatives of Jewish ancestry who lived in Eastern Europe (Ashkenazi Jews)? If yes, have either you or your partner been screened for Tay Sach s disease? If yes, indicate results and who was screened Dr Nick Lolatgis Pre-Consultation Questionnaire 5 of 6
6 Genetic Screening Questionnaire (continued) IVF Questionnaire 6. If you or your partner are African-American, have either of you (or any close relatives) ever been screened for sickle cell trait? If so, was the result positive for Hemoglobin Electrophoresis? If so, was the result positive for Glucose-6 Phosphate Deficiency? If yes, indicate results and who was screened 7. Do you or your partner have any close relatives descended from Mediter ranean countries? If yes, have you or your partner been screened for thalassemia (Cooley s anemia)? 8. Have you ever been tested to determine if you are immune to Rubella (German measles)? 9. Have you ever been tested to determine if you are immune to Varicella (Chicken pox)? 10. Congenital malformations such as cardiac, neurological, kidneys, liver, adrenal, phenylketonuria, congenital hypothyroidism, homocystinuria, dwarfism, neurofibromatosis, myotonic dystrophy, multiple sclerosis, cystic fibrosis, malignant hyperthermia, premature menopause? If yes, please indicate which one, where, when and results of tests: Please answer the following questions if you have previously been treated with In Vitro Fertilization (IVF) procedure. Number of Previous cycles Date(s) Location(s) Stimulation Clomiphene Citrate (Clomid) HMG FSH Other Outcome: Did you complete cycle(s)? If no, explain reason(s) Number of eggs obtained Were the eggs obtained by laparoscopy/ultrasound? Did fertilization occur? Number of embryos replaced (IVF) Outcome Do you have any embryos frozen? If yes, how many? Have you previously had a sperm penetration assay(hamster test, SPA)? If yes, when where? Results HFF ESP Percoll Dr Nick Lolatgis Pre-Consultation Questionnaire 6 of 6
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Overview and Definition Infertility is defined as the inability of a couple to fall pregnant after one year of unprotected intercourse. Infertility is a very common condition as in any given year about
Family Naturopathic Clinic Adult Intake and Consent Form
Health History Form (GENERAL) Name Birth-date Date MSP # Blood Type Address City Prov/State Postal Code Phone (home) Phone (work) best time to call Can we leave messages for you here? Y N Email Occupation
Tel: (312) Women s Integrated Fax: (312) Pelvic Health Program. 1.0: Basic Information. Preferred Language:
Tel: (312) 694-7337 Women s Integrated Fax: (312) 695-0156 Pelvic Health Program 1.0: Basic Information Date of Birth: / / Age: Home Address: Preferred Language: English Spanish Other: Email address: Preferred
New Patient History Form (Age 18 and over)
New Patient History Form (Age 18 and over) Obstetrics & Gynecology Name Age Date first middle last Occupation Marital Status: c Single c Married c Divorced c Widowed Referred to our office by: What is
Reproductive Health Questionnaire
133 Catherine St Leichhardt NSW 2040 ph: 9555 8806 email: reception@darlinghealth.com.au Reproductive Health Questionnaire Please attach to this completed form copies of any past pathology results including
Emergency Information: List nearest relative preferable not living with you.
Patient Information Label Last Name First Name M.I. Maiden or Nickname Street Address Apt. P.O.Box City State Zip Social Security # XXX- X - (last five) Birth / / Marital Status!Single!Married!Divorced!Widowed!Other
PATIENT HEALTH HISTORY
Name DOB Sex Age Date MR# PLACE CHARGE TICKET LABEL IN THE DASHED SPACE OR COMPLETE THE ABOVE: PLEASE ANSWER EACH QUESTION AS CORRECTLY AS YOU CAN BY PLACING AN "X" IN APPROPRIATE BOX What is the reason
Infertility: failure to conceive within one year of unprotected regular sexual intercourse. Primary secondary
Subfertility Infertility: failure to conceive within one year of unprotected regular sexual intercourse. Primary secondary Infertility affects about 15 % of couples. age of the female. Other factors that
NEW GYN PATIENT HISTORY FORM (OB PATIENTS, please DO NOT USE THIS FORM. Thanks.)
NEW GYN PATIENT HISTORY FORM (OB PATIENTS, please DO NOT USE THIS FORM. Thanks.) TODAY'S DATE Your age DATE OF BIRTH YOUR NAME (Last) (First) (M.I.) REFERRED HERE BY YOUR PAST MEDICAL HISTORY (If YOU have