Lori Arnold, M.D., F.A.C.O.G Reproductive Endocrinology and Fertility
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1 Lori Arnold, M.D., F.A.C.O.G Reproductive Endocrinology and Fertility NEW PATIENT HISTORY A. FEMALE IDENTIFYING DATA Date this form completed Your name: _ Partner s Name: Age Birth date Height Weight How long have you been trying to get pregnant? Have you previously been pregnant? Have you previously tried to get pregnant? Reason for your visit today? B. PREGNANCY HISTORY Times pregnant Term births Premature births Miscarriages Elective abortion Adopted children Pregnancies: Pregnancy (include all pregnancies ) First When? (Year) How long to conceive Sex and weight Is current partner the father (Y/N) Outcome (miscarriage, abortion, ectopic, vaginal delivery, cesarean section, stillbirth, complications if any. Second Third Fourth Fifth Contraceptive Use Intrauterine device (IUD) From when to when Reason discontinued Complications Oral contraceptives Type: Other
2 C. MENSTRUAL HISTORY Menstrual (hormonal) history Page 2 Date your last menstrual period began Your age at your first period Are your periods regular? How many days from onset to onset? How many days does your period last? Do you bleed between periods? Do you have premenstrual symptoms almost always rarely never Have you ever needed medication to bring on your period? Yes No If yes, what medication: When? If you have a hormonal disorder, please specify and treatment Pelvic pain/cramps: none during your period before your period after your period at mid-cycle during intercourse with urination with bowel movements cause you to miss usual activities cause you to miss work Pelvic cramps/pain are: mild moderate severe getting worse improving not changing on the right side on the left side in the middle What medications do you take for pain/cramps? Do you have painful intercourse: Yes No Do you have or have you had: Pelvic inflammatory disease (PID) Vision problems Intrauterine device (IUD) Chronic headaches DES exposure Head injury Breast discharge (galactorrhea) Seizure disorder Breast biopsy Weight gain (> 10 pounds) Thyroid disease. Weight loss (> 10 pounds) Increased facial or body hair Special dietary habits Loss of hair Vomiting Increased acne Excessive stress Decreased breast size Autoimmune disease Deepening of voice Psychiatric treatment Hot flashes or night sweats Poor sense of smell If you answered yes to any questions, please explain Rh sensitized D. GYNECOLOGICAL HISTORY Do you have or have you had: Abnormal uterus (shape, etc) Ovarian cysts Colitis or enteritis Pelvic adhesions Endometriosis Uterine fibroids or myomas
3 Gynecologist: Page 3 Primary Care Physician: Last Pap smear Any abnormal Pap smears?, dates Last mammogram Any abnormal mammograms? Do you have or have you had: Cryo (freezing) or surgery of the cervix Chlamydia Gonorrhea Genital warts/condyloma Herpes: Genital Vaginal discharge Mycoplasma/Ureaplasma Recurring vaginitis Syphilis Trichomonas Cytomegalovirus (CMV) Cervical stenosis Cervicitis Recurrent urinary infections Use of lubricants Douche before/after intercourse Bleeding/spotting after intercourse Sexual problems at this time If yes, explain: Yes No How many times per week do you have sexual intercourse? How many times do you have intercourse around ovulation? F. MEDICAL HISTORY Past Medical History Anemia Liver problems Appendicitis Lung disease Arthritis Lupus Asthma Migraine headaches Bleeding disorders Radiation exposure Blood clots Rheumatic fever Blood transfusion Toxic exposure Cancer Chronic bronchitis Diabetes Eating disorder If yes, explain List all serious or chronic illnesses or injuries not already described Tuberculosis Ulcers Chickenpox (varicella) Gallbladder problems Chickenpox vaccine Heart disease German measles (rubella) Hepatitis A, B or C Rubella immunization High blood pressure Kidney disease Kidney infection
4 Medications: Please list all prescriptions and over-the-counter drugs used during the past year. Page 4 Medication Dosage and frequency From when to when Reason for taking Allergies To what (drug or substance)? When What type of reaction? G. PAST SURGICAL HISTORY Operations and Hospitalizations Date Diagnosis Operation Where performed Physician Complications of anesthesia H. FEMALE FAMILY HISTORY Ethnic background (circle): African/American Asian Asian-Indian Caucasian Hispanic Jewish Indian Mediterranean Middle Eastern Other Ethnic group (Circle all that apply) Have you been tested for: Yes No Date Result African, African/American Asian, Mediterranean or Hispanic Caucasian, Jewish Jewish, Cajun, French Canadian Sickle cell trait Thalassemia Cystic fibrosis Tay Sachs Ashkenazi Jew Ashkenazi Jewish Panel (11)
5 Do any family members have: Page 5 Yes Who Yes Who Cancer of the uterus /breast/ovaries Hemophilia Birth defects, genetic (inherited) Infertility Bleeding disorders Irregular menstrual cycles Chromosomal disorders Lack of sense of smell Connective tissue disease Learning problems Cystic fibrosis Mental retardation / Autism / Fragile X Delayed development Metabolic disorders Down s syndrome Miscarriages (2 or more) Early menopause < 40 yrs old Muscular dystrophy Early puberty Short stature Endometriosis Spina bifida Excess body hair Stillborn child Genital abnormalities Spinal Muscular Atrophy Other H. SOCIAL HISTORY Cigarettes packs smoked/day Alcohol type and number of drinks/week Marijuana amount Other drugs type and amount Ever used intravenous drugs? How much do you exercise? Do you have a dog or cat? I. PREVIOUS EVALUATION Have you had: Not Result Approx Values Done Normal Abnormal date (if known) Basal body temperature (BBT) Urine LH surge Endometrial biopsy Blood tests: FSH LH Prolactin Thyroid tests (TSH, T4) DHEAS
6 Not Done Result Normal Abnormal Approx date Page 6 Values (if known) Testosterone Estradiol Progesterone Postcoital test Mycoplasma culture Chlamydia culture Antichlamydial antibodies Hysterosalpingogram (HSG) Ultrasound Kidney x-ray (IVP) Laparoscopy Hysteroscopy Karyotype Anticardiolipin antibodies Lupus anticoagulant Antinuclear antibodies (ANA) Coagulation screen Biochemistry/hematology panel Blood type Other K: PREVIOUS TREATMENT Clomiphene (Clomid, Serophene) HMG (Profasi) Injectable gonadotropins Approx dates taken Outcome
7 Progesterone Page 7 K: PREVIOUS TREATMENT (continued) Approx dates taken Outcome Lupron GnRH agonist (Synarel, Lupron) Intrauterine insemination (IUI) Insemination with donor sperm In vitro fertilization (IVF) ICSI GIFT Other Please use the remainder of this page to explain any additional information you think the doctor may need.
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