U.S. Naval Hospital Naples, Italy Infertility Questionnaire
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- Timothy Lawrence
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1 U.S. Naval Hospital Naples, Italy Infertility Questionnaire The following questions make up a screening questionnaire that will help us in caring for you during your pregnancy. Your answers may indicate whether certain tests would be appropriate in helping to evaluate the health of your unborn baby. If you have any questions, please ask your health care provider. Name SSN of sponsor Rank/Rate(active duty) Duty Station Phone# (H) (W) Age HT (Pre-pregnancy) WT Race Religious Preference Primary Language Single Married Divorced Widowed Name of Baby s Father Rank/Rate Race Age Duty Station Phone # Fertility History 1. Have you had an infertility work up in the last year? 2. Have you taken infertility drugs in the past year? 3. Had you been using birth control prior to conception? (i.e. Pill, IUD, foam, condom, diaphragm, sponge, rhythm method) Circle all that apply. When did you stop? 4. How long have you had unprotected intercourse to become pregnant? months or years 1. How many times per week do you have unprotected intercourse? x / wk Medical History 1. Have you ever been hospitalized If so, for what diagnosis 2. Do you have any chronic health problems? 3. Do you routinely have headaches, (prior to pregnancy)? 4. Do you have, or have you ever had, seizures or convulsions? 5. Do you have any problems with your vision or eyes? (not including wearing contacts or glasses) 6. Have you ever had problems with your thyroid gland? What? 7. Have you ever had problems with your lungs? (i.e. pneumonia, asthma, bronchitis, tuberculosis) 8. Have you ever had problems with your heart? (i.e. heart murmur, rheumatic heart disease, heart surgery, heart attack, high blood pressure) 1
2 Medical History continued 9. Do you have problems with your stomach or intestines, i.e. constipation, diarrhea, hemorrhoids (before pregnancy)? 10. Have you ever had a blood transfusion? When? 11. Have you been told by a health care provider that you are anemic? When? 12. Are you seeing a health care provider for problems with your muscles or bones? 13. Have you had any mental or psychiatric problems that required counseling? 14. Do you have any other health problems that we should know about? Explain: 15. Have you had or been immunized for: a. Rubella (German measles or 3 day measles) b. Rubeola (two week, hard, or red measles) c. Varicella (Chicken Pox) d. Hepatitis B e. Hepatits A 16. Have you ever had a positive PPD? Were you treated? Medications 1. Do you take any medications routinely? What and how often? Allergies 1. Do you have allergies to any medications? If yes, which medication and what type of reaction? 4. Do you have allergies to any foods? 5. Do you have a latex allergy? Surgical history 1. Have you ever had any operations or surgeries? What and when? PATIENT IDENTIFICATION 2
3 Social History 1. Do you smoke? How many packs/day? How many years? 2. Do you drink alcoholic beverages? How many drinks/week? 3. Do you/have you used illicit or illegal drugs if so, what 4. Are you currently employed if so, what What type of job? _ 5. Do you have heat in your home? 6. Do you have a phone in your home? 7. Have you ever been the victim of sexual, physical or emotional abuse? Obstetric History 1. Number of past pregnancies 2. Number of miscarriages and/or abortions 3. Number of children now living If yes, answer date (chronological order), weight,.method of delivery and any complications. 4. Have you ever received Rhogam? Gynecologic & Menstrual History 1. Age at first menstrual period 2. How often are your periods? Every days, lasting days. 3. Do you usually have severe cramping with your periods? 4. What was the first day of your last NORMAL period? Yes No 5. Have you had the following: a. unusual breast lumps or discharge from the nipples b. repeated vaginal infections, pelvic inflammatory disease c. abnormal pap smears d. sexually transmitted diseases e. infections of the uterus, tubes or ovaries f. abnormal hair growth pattern, fascial hair, excessive body hair? g. surgery of your tubes, ovaries, uterus or vagina h. pain with intercourse i. use of gels or lubricants during intercourse? j. diagnosis of fibroids, DES exposure, ectopic pregnancy. Circle appropriate PATIENT IDENTIFICATION 3
4 Educational History 1. How many years of school have you completed? 2. How many years of school has your partner completed? 3. Do you plan on taking childbirth preparation classes? Family History 1. Do you or the father of the baby have any close family members with: diabetes cancer tuberculosis high blood pressure heart attack heart problems twins bleeding problems cystic fibrosis Down s syndrome hemophilia mental retardation spina bifida muscular dystrophy anencephaly hydrocephalus 2. Will you be 35 or older when this baby is due? 3. Do you or the baby s father have any known birth defects? Please list: 4. Have you or the baby s father had a child born (alive or dead) with a birth defect not listed in the above questions? 5. Are there any known inherited or chromosomal disorders in the family? 6. Are you and the baby s father related outside of marriage? (such as cousins) Genetic History 1. Are you or the father of the baby of African American descent? Have you been tested for sickle cell trait? 2. Are you or the father of the baby of Eastern European Jewish descent? Have you been tested for Tay-Sachs carrier? 3. Are you or the father of the baby of Asian or Mediterranean descent? Have you been tested for Thalassemia trait? 4. Any history of Cystic Fibrosis in your or your partner s family? 5. Any history of mental retardation in your or your partner s family? 6. Are there any other genetic abnormalities in your or your partner s family history? PATIENT IDENTIFICATION 4
5 Male history 1. How long has he been your partner? 2. Has he fathered other children? a. If yes, how many 3. Past medical history 4. Past surgeries? a. If yes, what type(s) 5. Has he been exposed to radation? 6. Has he been exposed to hazardous chemicals? a. If yes, what types? 7. Any trauma or surgery to his genitalia/testicles? 8. Any history of sexually transmitted diseases? 9. Any history of mumps? 10. Any problems with ejaculation or erection? 11. Is he taking any medications? a. If yes, what types? I have completed this History and Physical form to the best of my knowledge. Failure to provide adequate and/or truthful information could adversely affect my physician s ability to treat my infertility and inadvertently have a negative impact on my health and well being. Patient signature Date I have reviewed the following History and Physical form provided by the patient listed. Physician signature Date PATIENT IDENTIFICATION 5
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PLACE LABEL IN THIS SPACE 1800 Northside Forsyth Drive, Suite 380, Cumming, GA 30041 CARLA ROBERTS, MD, PHD CYNTHIA WITT, FNP-C ROOM#: NEW PATIENT FORM Name Date of Service Present Age Physician who referred
Margie Petersen Breast Center
Medical History Questionnaire Name: Sex: Female Male Last First Middle Date of Birth: Age: Birth Place: Mother s Birth Name: Social Security #: - - Marital Status: Single Married/Partnered (how long) Divorced
HEALTH HISTORY QUESTIONNAIRE. Family Risk Assessment Program
HEALTH HISTORY QUESTIONNAIRE Family Risk Assessment Program Name DOB Current Age Address Home Phone Cell Phone Business Phone Best time to contact you Day Evening E-mail Address (Email will only be used
Name Age Date. Address Phone. Name of Physician. Address Street Address City State Zip Code
Name Age Date Address Phone What is the reason for your visit today? Where have you been receiving your medical care? Name of Physician Address Street Address City State Zip Code PAST MEDICAL HISTORY: