WOMEN & INFANTS HOSPITAL 101 Dudley Street Providence, RI CENTER FOR REPRODUCTION AND INFERTILITY INFERTILITY QUESTIONNAIRE.
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- Mabel Melton
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1 Page 1 of 6 If you need help filling out this form, please contact us and we will have someone help you. You may be asked to come in ½ hour earlier than your scheduled appointment to answer your questions. IDENTIFYING INFORMATION Name: Name by which you wish to be addressed: Birth Date: Age: Home phone number: Cell number: Work phone number and hours: ext. Hours: Pharmacy name and phone number: Chief Complaint (reason for visit): If Infertility, duration (years): Today s Date: BASIC INFORMATION Who referred you? Who is your gynecologist if different from above? What is your occupation? Are you married date single long-term relationship other: What is your partner s name? What is your partner s birth date? How many years have you been with your present partner? What is your partner s occupation? HEALTH STATUS Do you have any allergies to any medicines? If so, what are the allergic reactions? Do you take any current medications (including vitamins & folic acid)? MENSTRUAL HISTORY What was your last menstrual period? How old were you when you started your periods? How many days between the first day of one period and the first day of the next period? Would you describe your periods as: heavy moderate light Are your periods: regular irregular Are your periods painful? Would you describe that pain as: moderate severe mild GYNECOLOGIC HISTORY Do you have hair on your face that is concerning? Do you have acne? Do you use lubricants for sex? What type: Do you douche? Do you have pain with intercourse?
2 Page 2 of 6 Have you ever had an abnormal pap smear? Have you had a pelvic infection? Have you had any sexually transmitted diseases? Have you ever used any contraception? If yes, please check: oral contraceptives IUD condoms other: How often do you have sex? SOCIAL HISTORY Do you smoke? If yes, how many cigarettes per day? Do you drink caffeine? If yes, how many cups per day? Do you drink alcohol? If yes, how many drinks per week? Do you take recreational drugs? Do you exercise? If yes, how many hours per week? OBSTETRICAL HISTORY How many times have you been pregnant? For each pregnancy, please fill in the following chart: #1 #2 #3 #4 Month/year pregnancy ended Pregnancy outcome (# of weeks: ) w/o D&C w/o D&C (# of weeks: ) w/o D&C (# of weeks: ) w/o D&C (# of weeks: ) With current partner? Time it took to get pregnant? Infertility Therapy Sex of Baby Weight of Baby Pregnancy complications
3 Page 3 of 6 PRIOR FERTILITY TESTING AND MEDICATION Have you used any of the following, please check: Basal body temp monitoring Ovulation predictor kit Artificial insemination partner donor Clomiphene Femara/Letrozole Gonadotropins (fertility shots) In Vitro Fertilization Have you ever had an x-ray (HSG) of your uterus and tubes? If yes, where was it done? WIH or e ewhere Please bring disk/images with you. What were the results? Have you ever had a sonohysterogram (ultrasound with saline) of your uterus and tubes? If yes, where was it done? WIH or e ewhere Please bring disk/images with you. What were the results? Has your partner had a semen analysis? N/A If yes, where was it done? WIH or e ewhere If yes, what were the results? PAST MEDICAL HISTORY Do you have antibiotic therapy before dental work or a surgical procedure to protect your heart? Do you have a history of clots in your legs or lungs? Have you had a stroke or heart attack? Have you ever been told you had any of the following? Anemia Bleeding tendency Prior blood transfusion Lung disease Heart disease High blood pressure Cancer If yes, type and treatment Chronic headaches Seizures Depression Diabetes Thyroid disease Gall bladder disease Stomach reflux (GERD) Irritable bowel syndrome Liver disease/hepatitis Infection in your kidneys/bladder
4 Page 4 of 6 PREVIOUS HOSPITALIZATIONS OR INPATIENT/OUTPATIENT SURGERIES Please list any time you were in the hospital, the reason, and the year; list all your surgeries as well. GYNECOLOGIC SURGERY If you have had any of the following, please list the dates: Tubes and ovaries removed D&C; cone D&C, Leep Treatment of endometriosis, medical or surgical Hysteroscopy (view inside of uterus) Laparoscopy (view inside abdominal cavity and pelvis) Lysis of adhesions (scar tissue removal) Fibroid removal Hysterectomy (uterus removal) Cutting of a uterine septum Tubal ligation Tubal ligation reversal Date FAMILY HISTORY Age Living # of miscarriages Cancer Chromosomal Diabetes High blood pressure Mother Father Sister Sister Brother Brother PARTNER S HISTORY Has your partner had any pregnancies with another partner? Does your partner use recreational drugs? Does your partner smoke or use tobacco? Does your partner drink alcohol? Drinks per week: Drinks per month: Has your partner ever had a sexually transmitted disease? Is your partner allergic to any medications? What medicines does your partner now take?
5 REVIEW OF SYSTEMS Page 5 of 6 Do you have any of the following: Fever... Chills... Sweats... Loss of appetite... Tiredness... Weight loss... Blurred vision... Double vision... Burning eyes... Discharge from your eyes... Loss of vision... Eye pain... Pain with bright lights... Ear pain... Ear discharge... Ringing in your ears... Decreased hearing... Blockage of your nose... Nosebleeds... Sore throat... Hoarseness... Difficulty swallowing... Chest pain... Fast heartbeat... Fainting... Difficulty breathing... Difficulty breathing while you re laying down... Swelling of your feet or hands... Itching... Rash... Dryness... Suspicious lesions on skin... Unable to move arms or legs... Weakness... Tingling in fingers, toes, arms or legs... Seizures... Fainting... Shaking... Dizziness... Depression... Anxiety/nervous condition... Memory loss... Mental illness... Suicidal thoughts... yes... no Hallucinations... Cough... Coughing up phlegm... Coughing up blood... Wheezing... Nausea... Vomiting... Diarrhea... Constipation... Change in bowel habits... Abdominal pain... Blood in your stools... Black stools... Yellow skin... Yellow eyes... Vaginal discharge... Loss of urine... Painful urine... Blood in your urine... Frequent urination... No menstrual periods... Abnormal vaginal bleeding... Pelvic pain... Back pain... Joint pain... Joint swelling... Muscle cramps... Muscle weakness... Stiffness or pain in your joints... Paranoia... Cold intolerance... Heat intolerance... yes no Excessive drinking... Excessive eating... Excessive urination... yes no Weight change... Abnormal bruising... Bleeding... Enlarged lymph nodes... Hives... Hayfever... Persistent infections... HIV exposure...
6 Page 6 of 6 BACKGROUND INFORMATION 1. Have you ever had or been vaccinated for Chicken Pox? 2. Have you ever had or been vaccinated for Hepatitis? 3. Have you ever been vaccinated for Rubella (German Measles)? 4. Do you or your partner or any family member have a birth defect? If yes, who has the defect and what is it? 5. Have any of your previous pregnancies, if any, resulted in a birth defect? If yes, what was the defect? 6. Do you or your partner or any family member have Cystic Fibrosis? If yes, who has cystic fibrosis? 7. Do you or your partner or any family member have Down Syndrome? If yes, who has Down Syndrome? 8. Do you or your partner or any family member have hemophilia? If yes, who has hemophilia? 9. Do you or your partner or any family member have Muscular Dystrophy? If yes, who has Muscular Dystrophy? 10. Do you or your partner or any family member have a neural tube defect? If yes, who has the defect and what is it? 11. Do you or your partner or any family member have any other chromosomal abnormalities? If yes, who has the abnormality and what is it? 12. Do you or your partner or any family member have mental retardation? If yes, who has mental retardation? 13. Are you or your partner of Ashkenazi Jewish ancestry? myself partner both If yes, have you/partner been screened for Tay-Sachs disease? Cystic Fibrosis? 14. Are you or your partner black? myself partner both If yes, have you/partner been screened for sickle cell? 15. Are you or your partner of French-Canadian ancestry? myself partner both If yes, have you/partner been screened for Tay-Sachs disease? Cystic Fibrosis? 16. Are you or your partner of Italian, Greek, Portuguese or Mediterranean background? myself partner both If yes, have you/partner been tested for ß-thalaseemia? 17. Are you or your partner of Philippine, Southeast Asian, or Indian ancestry? myself partner both If yes, have you/partner been screened for α-thalaseemia? Form completed by Name: Date: Time:
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Patient Name (First Middle Last) Date of Birth Social Security # Address City State Zip Home Phone Work Phone Cell Phone Other Phone Email Place of Birth Occupation Retired Yes No Gender Male Female Status
Address Street Address City State Zip Code. Address Street Address City State Zip Code
Male Initial Visit Intake Form PATIENT INFORMATION Today s Date Last Name Mid Initial First Name Date of Birth Address Home Phone Social Security Number Street Address City State Zip Code Cell Phone E-mail
Please list all medications you are currently taking (include aspirin, vitamins, hormones), Dosage, and Frequency.
GENERAL SURGICAL ASSOCIATES A practice of Lehigh Valley Physician Group Suite 208 ~ 1240 S. Cedar Crest Boulevard ~ Allentown, PA 18103 Phone: (610) 402-9780 PLEASE COMPLETE THIS FORM PRIOR TO YOUR VISIST
Broward Oncology Associates, P.A. PATIENT INFORMATION
NAME: BIRTHDATE: AGE: LOCAL ADDRESS (Street city state zip): HOME TELEPHONE# CELL # SOCIAL SECURITY #: - - SEX MARITAL STATUS WHAT IS YOUR HT? WHAT IS YOUR WT? EMPLOYER WORK# SPOUSE'S NAME SPOUSE'S EMPLOYER
Form.NewPatientHstory_PrecisionEndoRev Page 1 of 5
Patient s Name (First, Middle, Last): Address: City: State: Zip Code: Email: Main Contact#: Alternate#: Work#: Date of Birth: / / Sex: Male Female SS# (optional): Marital Status : Single Married Divorced
NEW PATIENT INFORMATION FORM
UNIT NUMBER PT. NAME UCSF Medical Center AMBULATORY SERVICES BIRTHDATE LOCATION DATE Today s Date / / What is the reason for your visit today? Where have you been receiving your medical care? Name of Physician
NEW PATIENT HEALTH HISTORY
NEW PATIENT HEALTH HISTORY Patient Name Today s Date Age Birth Date Date of last physical examination What is your reason for initial visit? Pharmacy Name & Telephone # NOTE: If you have prior records
Women's Health, Naturally Fertility Questionnaire
Women's Health, Naturally Fertility Questionnaire Name : Age: Date of Birth: Tel. #-Day: - - Evening: -- - Partner's Name: Partner's date of birth: GYNECOLOGICAL HISTORY How old were you when you had your
SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET
SECTION OF NEUROSURGERY PATIENT INFORMATION SHEET EC#: (for office use only) Patient s Name: Today s Date: Age: Date of Birth: Height: Weight: Physician you are seeing today: Marital Status: Married Work
UROGYNECOLOGY MEDICAL HISTORY QUESTIONNAIRE
UROGYNECOLOGY MEDICAL HISTORY QUESTIONNAIRE Name: Age LMP Date: Pregnancies Births (Vaginal C/S ) Term Preterm Miscarriage/Abortion Living Weight of largest vaginal delivery Allergies: None Yes Reaction
NEW PATIENT HISTORY QUESTIONNAIRE
NEW PATIENT HISTORY QUESTIONNAIRE Patient Information: Date Name: Birth date: Who referred you to this clinic? Who is your primary physician? Location/Address: Do you need a referral? Yes No Would you
TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM
TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM PATIENT NAME: DATE OF BIRTH: TVA Physician being seen: Date of Visit: PAST MEDICAL HISTORY HEART PROBLEMS NEUROLOGICAL Congestive Heart Failure
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
Center for Advanced Wound Care New Patient Questionnaire Page 1 of 6
Center for Advanced Wound Care New Patient Questionnaire Page 1 of 6 These questions are general screening questions designed to identify areas where additional attention may be required. Please bring
Silver Child Development Center New Patient Questionnaire. Relation (circle) Biological Mother Stepmother Adoptive Mother
Silver Child Development Center New Patient Questionnaire Today s Date Mother s Name First Last Date of Birth Relation (circle) Biological Mother Stepmother Adoptive Mother Foster Mother Other Father s
Modesto Gastroenterology Medical Corporation
Page 1 of 5 Modesto Gastroenterology Medical Corporation Magdy S. Elsakr, M.D. Board Certified Gastroenterologist 2336 Sylvan Avenue, Suite A, Modesto, CA 95355, Phone: 209-338-0292, Fax: 209-338-0298
The information you provide us will greatly help us provide the highest quality and most comprehensive care for you.
Rheumatology (circle location of appointment) 111 Hundertmark Rd. Suite 115N 560 S. Maple St. Suite 400 place patient label here Chaska, MN 55318 Waconia, MN 55387 952-361-2450 952-361-2450 The information