16 East 40 th St, 2 nd Fl, New York, NY Ph fax
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1 Page 1 of 9 16 East 40 th St, 2 nd Fl, New York, NY Ph fax Please complete the following: Fertility Evaluation Name: Date of birth: Age: Partner s Name: Date of birth: Age: Primary care provider: OB-GYN provider: How were you referred to us? Last Menstrual Period: On active birth control/ type? REASON FOR TODAYS VISIT? Obstetrical History: How long have you been trying to get pregnant? Have you ever been pregnant? Have you been pregnant with your current partner? Preg. # Year Time to conceive Type of fertility treatment? (If any) Weeks carried Outcome (e.g. Live, fetal heartbeat, miscarriage, D&C, genetic testing results) Type of delivery Complications Current partner?
2 Page 2 of 9 Gynecologic History: When was your last Pap smear? Result: Have you had a mammogram? Do you experience pain with intercourse? Do you experience the pain externally or with deep penetration? Vaginal discharge? Is it associated with an odor, itching, or burning? Did you have a tubal ligation? Reason? Please include dates and treatment if you ever had: Mother who took DES: Pelvic infection: Chlamydia/gonorrhea: Herpes: Vaginitis: Endometriosis: Ovarian cysts: Genital warts: Abnormal Pap:
3 Page 3 of 9 List dates and nature of any pelvic surgery: Have you ever had a tubal ligation? If so, give details Birth Control: Have your ever used the following? Birth control pills, IUD, diaphragm, condoms, norplant, depo-provera, foam, sponge, other? Method Dates How long? Why did you stop? Complications Menstrual History: Date of last menses: Age at onset of your menstrual period: Average length between cycles (from day 1 of full flow to next next day 1): Any history of irregular menses, spotting, or missed menses? If yes, please explain (include dates): Amount of bleeding: Light Medium Heavy Have you taken medications to induce a period? Painful menses? Does the pain start with bleeding? Does the pain last longer than 48 hours? Please list any medications you take for cramps:
4 Page 4 of 9 Ovulation History: Do you experience: Premenstrual cramps? Clear discharge mid-cycle? Monthly cycles? Pain at midcycle? Have you ever used the following: Basal body temperature: months. Temperature shift: Day of shift: Ovulation predictor kit: # cycles: LH surge? Yes No Day of LH surge: Hormonal Assessment: Have you ever experienced any of the following: Weight gain/loss of 10+ pounds Discharge or milk from nipples Change in vision Unusual sensitivity to hot or cold Excessive change in hair growth/loss Acne or oily skin Thyroid disease, diabetes, or other hormonal abnormalities Medical History: Please list any medical/psychiatric conditions that you have or had in the past and any medications used in treatment. List dates.
5 Page 5 of 9 Surgical/Hospitalization History: Please list any surgeries or hospitalizations you have had. List dates. Family History: Please list any family history of infertility, genetic problems, thyroid disease, diabetes, cancer, or any other major medical problems. Social History: Occupation: Travel for work: Frequency: Caffeine intake: Do you smoke cigarettes? Packs per day Alcohol consumption: drinks/week Type: How frequently do you have intercourse? per week/month Medications: Prescription Over the counter Recreational (marijuana, hallucinogens, crack/cocaine) List the form and frequency of any regular exercise Have you ever been told you have or suspected you have an eating disorder?
6 Page 6 of 9 Previous Infertility Treatment: Please describe results and include dates. Name of physician/practice: Has your partner ever had a semen analysis? If yes, please provide a copy of the results and complete the following: Volume: Concentration (million cell/ml): Motility (%): Morphology (% of normal forms): Have you had any hormonal blood tests? Have you ever had an endometrial biopsy? Have you ever had an HSG (x-ray of your tubes and uterus)? Have you ever had a saline ultrasound (fluid ultrasound)? Have you ever had a laparoscopy or laparotomy? Have you ever taken fertility medications? Have your ever had intrauterine inseminations? # of cycles Outcome: Have you had IVF before? # of cycles Outcome:
7 Page 7 of 9 Details of past IVF treatments Clinic Date Type of cycle (fresh or frozen) Stimulation Protocol # eggs #embryos Result Frozen embryos remaining Reason for leaving clinic Have you ever used donor eggs, donor sperm, or a gestational carrier? # of cycles Outcome: Comments: Please describe why you believe you are unable to get pregnant. Male History: Occupation: Weight: Height: Allergies: Reaction: Current medications: Have you been evaluated by an urologist?
8 Page 8 of 9 If yes, please provide diagnosis: Do you use tobacco? Alcohol consumption: drink per week/month Do you use any recreational drugs? Type If yes, please explain type and frequency: Do you use a hot tub? Medical History: Please explain any positive answers. History of mumps? Complications? History of undescended testicles? Any illness and/or high fever in the last 6 months? Have you ever had x-rays to your groin area? Have you ever had any injury or cancer tumor of the groin area? Have you ever been treated for a genital infection? (e.g. chlamydia, gonorrhea, herpes, syphilis, other) Do you have any other medical problems? Please provide dates and treatment. Surgical History: Please provide date and surgeon. Hernia repair: Testicular surgery: Pelvic surgery: Varicocele repair: Vasectomy: Vasectomy reversal: Testicular biopsy: Testicle removal:
9 Page 9 of 9 Testicle fixation (orchipexy): Sexual History: Do you have any difficulty having or maintaining an erection? Do you experience premature ejaculation? Any other sexual difficulties? (Please describe) Yes No Yes No Yes No Person completing this form: Signature: Date: The above information was reviewed with patient on: Date Physician Name: Signature
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