Female Consultation Questionnaire
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- Lionel Allen
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1 Female Consultation Questionnaire In order to schedule a consultation with the doctor, an overview of your medical history along with a copy of your medical records are requested. Dr. Zouves will review them in advance of the consultation to maximize appointment time. Complete this form and to kim@goivf.com or fax to Please print Legal Name: Date of Birth: Preferred Name (if different than above): Mailing Address (include city, state and zip code) Home phone: Cell Phone: Choose one: single married unmarried registered domestic partners How were you referred to us? Physician Patient Radio Newspaper Word Of Mouth Internet Other Name of Referral:
2 Last Contraceptive Used: Stopped: Have You Done Any Acupuncture:! Yes No Acupuncturist Name: Herbs: Are You Allergic To Any Medications? Are You Currently Taking Any Medications Or Supplements? If yes, please list: Have You Ever Been Pregnant (live birth, miscarriage (SAB), termination (TAB), chemical or ectopic)? Yes No A) Total Number Of Pregnancies Live Birth(s) Miscarriage(s) Termination(s) Chemical Ectopic(s) B) Dates Of Pregnancy: Please include how many weeks, with current or previous partner, result and through natural conception or assisted reproduction: Pregnancy#1: Pregnancy #2: Pregnancy #3: Pregnancy #4:
3 Pregnancy #5: If applicable, what have doctors diagnosed as the infertility problem? Male Infertility Tubal Disease/Pelvic Adhesions Endometriosis (Mild, Moderate Or Severe?) Unexplained Infertility Immunology Uterine Ovulatory Dysfunction Other Doctor s Name: Year Diagnosed: Are you currently in cycle with another fertility center? Female History Weight Height How old were you when you started your menstruation? How long between menstruation cycles? (i.e. Every 28 to 30 days) How many days does your menstruation last (actual days of bleeding)? Have you been diagnosed with any ovulation problems or hormonal imbalances?
4 Have you been tested for the following hormones? If yes, mark any normal or abnormal results. Follicle Stimulating Hormone (Fsh): Estradiol (E2): Thyroid Hormones (Tsh): Anti-Mullerian Hormone (AMH): Prolactin: Progesterone: Have you ever undergone one or more of the following pelvic surgeries? Surgery To Repair Ovaries Or Unblock Tubes! Ectopic Pregnancy/Surgery! Tubal Ligation! Endometriosis (Please circle stage I, II, Or III)?! Removal Of Scar Tissue, Polyps, Cysts, Etc. From Inside Of Uterus! Removal Of Fibroids From Uterus! Hysterectomy/Removal Of Ovaries! Have you ever had a Hysterosalopinogram (HSG) dye inserted into tubes for an x-ray)? If yes: Year the test was performed: Were the tubes clear or blocked?
5 Doctor s Name Year Have you had a Laparoscopy (minor surgery where a small incision is made near the belly button)? If yes: Year the test was performed: What were the findings? Doctor s Name Year Have you had a Hysteroscopy (non-surgical procedure where a telescopic instrument is inserted vaginally to look at the muscle wall of the uterus; not an ultrasound)? If yes: Year the test was performed: What were the findings? Doctor s Name Year Have you had a Hystero-Ultrasonogram (HUS) (sterile water instilled into the uterine cavity and an ultrasound scanner checks for polyps or fibroids)? If yes: What were the findings? Doctor s Name Year
6 Health History Hot Flashes! Asthma! Hepatitis! Cancer! Rheumatoid Arthritis! Lupus! DES Exposure! Pelvic Inflammatory Disease! Intrauterine Disease (IUD)! Exposure To TB! Positive PPD (Purified Protein Derivative)! Endometriosis!
7 Sexually Transmitted Diseases! Visual Disturbances! Thyroid Disorder! Increased Facial or Body Hair! Increased Acne! Weight Gain or Loss of 10lbs! High Blood Pressure! Diabetes! Auto Immune Disease! Psychiatric Treatment Seizures Family History Ethnic Origin/Ancestry
8 Mothers Ancestry: Father s Ancestry: Do You Have Any Of The Following Heritages? Jewish French Canadian African Ancestry Mediterranean (i.e. Italian, Greek) South East Asian Cajun Please List Family Members Connected to Below Conditions (i.e. Maternal/Paternal Grandmother, Grandfather, Mother, Father, Brother, Sister, Aunt, Uncle) Thyroid Disease! Rheumatoid Arthritis! Lupus! Other Auto Immune Recurrent Miscarriage! Diabetes! High Blood Pressure! Heart Disease! Stroke! Colon Cancer
9 Ovarian Cancer Breast Cancer Prostate Cancer Cancer (Other) Neural Tube Defect! Premature Menopause Uterine Fibroids Endometriosis Hereditary Conditions: Thalassemia Tay-Sachs Disease! Sickle Cell Anemia Cystic Fibrosis Muscular Dystrophy!
10 Huntington s Chorea Mental Retardation Fragile X! Baby With Birth Defects Bleeding Disorder Autism! Past Fertility Treatment Have You Been Treated With The Following? Clomid/Serophene/Femera: If so, how many cycles total? Injectable Gonadotropins: If so, how many cycles total? Have you undergone an IUI cycle(s)? If yes, please list each cycle below: Cycle Date Meds Outcome Dr. & Location 1 2
11 IVF History Please list each individual, IVF, FET or any cancelled cycles. Indicate if you used your own eggs, an egg donor, a sperm donor, and/or surrogate, and if the cycle was a frozen embryo transfer. Please include cancelled cycle(s) or cycle(s) that turned to IUI. Cycle Number: Date: Fertility Center: Fresh Cycle -Frozen Cycle: What Fertility Medications Or Protocol? How Many Eggs Retrieved?
12 How Many Fertilized? ICSI Assisted Hatching Split/ICSI PGD/CCS How Many Transferred? Day Transferred: How Many Frozen? Was This Cycle Converted To IUI Or Cancelled:! Yes!No Outcome:! Positive! Negative!Chemical! Miscarriage! Ectopic Cycle Number: Date: Fertility Center: Fresh Cycle -Frozen Cycle: What Fertility Medications Or Protocol? How Many Eggs Retrieved? How Many Fertilized? ICSI Assisted Hatching Split/ICSI PGD/CCS How Many Transferred? Day Transferred: How Many Frozen? Was This Cycle Converted To IUI Or Cancelled:! Yes!No Outcome:! Positive! Negative!Chemical! Miscarriage! Ectopic Cycle Number: Date:
13 Fertility Center: Fresh Cycle -Frozen Cycle: What Fertility Medications Or Protocol? How Many Eggs Retrieved? How Many Fertilized? ICSI Assisted Hatching Split/ICSI PGD/CCS How Many Transferred? Day Transferred: How Many Frozen? Was This Cycle Converted To IUI Or Cancelled:! Yes!No Outcome:! Positive! Negative!Chemical! Miscarriage! Ectopic Cycle Number: Date: Fertility Center: Fresh Cycle -Frozen Cycle: What Fertility Medications Or Protocol? How Many Eggs Retrieved? How Many Fertilized? ICSI Assisted Hatching Split/ICSI PGD/CCS How Many Transferred? Day Transferred: How Many Frozen?
14 Was This Cycle Converted To IUI Or Cancelled:! Yes!No Outcome:! Positive! Negative!Chemical! Miscarriage! Ectopic Please note any other items that you would like to have Dr. Zouves review:
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