REPRODUCTIVE ENDOCRINOLOGY AND INFERTILITY GROUP

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1 REPRODUCTIVE ENDOCRINOLOGY AND INFERTILITY GROUP NEW PATIENT EVALUATION FORM Name: Age: Partner: Age: Reason for Referral: Date of Appt: Have you ever seen any other physician(s) for this problem? Name: Address: Name: Address: Name: Address: MENSTRUAL HISTORY: Dates seen: Telephone: Send medical progress reports to this doctor 0 Yes 0 No Dates seen: Telephone: Send medical progress reports to this doctor 0 Yes 0 No Dates seen: Telephone: Send medical progress reports to this doctor 0 Yes 0 No Age of first period: Are your periods regular? 0 Yes 0 No Number of periods/year off medication? How many days between the first day of one period and the first day of the next? Date last menstrual period started: For how many days do you normally bleed? Do you have cramps with menses? 0 no 0 mild 0 severe Do you have diarrhea with your period? 0 Yes 0 No Do you take medication for cramps? 0 Yes 0 No (specify medication and number of days) Do you bleed or spot between your periods? 0 Yes 0 No I have other relatives with abnormal menstrual periods Do you spot before your periods? 0 Yes 0 No 0 Yes 0 No 0 Don't Know Did your mother take DES when she was pregnant with you? Did she smoke during her pregnancy? 0 Yes 0 No 0 Don't Know 0 Yes 0 No 0 Don't Know Date of last Pap smear: Result: Date of last mammogram: Result: CONTRACEPTION: Have you ever used an IUD? 0 Yes 0 No When? Contraception Dates used Reason for stopping PREGNANCY HISTORY: Total pregnancies: Full term deliveries: Premature deliveries: Miscarriages: Abortions: Ectopics: Date Type of Name Weight Weeks Infertility Time to Present Complications delivery gestation conceive partner

2 New patient evaluation form Page 2 PAST MEDICAL HISTORY List allergies to medications: List current medications: Do you have or have you ever had any of the following? (check ail that apply) o AIDS or positive HIV o Thyroid problems o Anemia/thalassemia o Seizures/epilepsy o Ovarian cysts o Blood transfusions o Genetic disorder o Heart disease o Alcoholism o Endometriosis o Measles: regular o Birth defects o Varicose veins o Mental illness o Pelvic infection (PID) o Measles: German o Liver problems o Sickle cell or trait o Eating disorder o Herpes o Mononucleosis o Hepatitis o Lung disease o Depression o Gonorrhea o Mumps o Ulcers/colitis o Kidney infection o Drug addiction o Chlamydia o Tuberculosis o Gallbladder problems o Kidney stones o Arthritis o Ureaplasma infection o Diabetes (juvenile) o High blood pressure o Migraines o Lupus o Osteoporosis o Diabetes (pregnancy) o Rheumatic fever o Neurological problems o Abnormal Pap smear o Sexual abuse/rape _ SURGERY Date Hospital MD Operation Findings Complications REVIEW OF SYSTEMS Do you now have any of the following? (check al/ that apply) o Abnormal hair growth o Hair loss o Acne o Bleeding problems o Breast lumps/discharge o Diarrhea o Constipation o Nausea o Shortness of breath o Chest pain o Heat/cold intolerance o Loss of sexual desire o Sexual problems o Loss of taste/smell o Painful intercourse o Skin rash o Urinary frequency o Painful urination o Urinary leakage o Visual problems o Chronic headaches o Muscle weakness o Fever o Weight changes o Other symptoms SOCIAL HISTORY Patient's Occupation: Education: Hobbies: 0 Exposure to chemicals (Iist) 0 Tobacco use packs/day age started age quit 0 Alcohol drinks/wk 0 Street drugs 0 Aerobic exercise hrs/wk 0 Running miles/wk Is this your first marriage 0 Yes 0 No 0 N/A If no how many times have you been married? How long have you been married? Partner's Occupation: Education: Hobbies: Exposure to hot tub, sauna. chemicals (Iist) 0 Tobacco use packs/day age started age quit 0 Alcohol drinks/wk 0 Street drugs 0 Aerobic exercise hrs/wk 0 Running miles/wk Is this your first rnarriaqe? 0 Yes 0 No 0 N/A If no how many times have you been married? Do you have children with a prior partner? 0 Yes 0 No

3 New patient evaluation form Page 3 GENETIC HISTORY FEMALE Has anyone in your family had one or more infants with serious birth defects? 0 Yes 0 No Comment: Has anyone in your family had two or more miscarriages? 0 Yes 0 No Comment: Do you or anyone of your family have any of the following conditions? (check al/ that apply) 0 Down syndrome 0 Kidney or bladder 0 Congenital heart 0 Loss of muscle 0 Spina bifida malformation disease function meningomyelocele 0 Club foot 0 Cystic fibrosis 0 Cleft lip or palate 0 Diabetes (juvenile) 0 Diabetes (adult) 0 Tay Sach's disease 0 Pyloric stenosis 0 Neural tube defect 0 Huntington's disease 0 Early senility 0 Early menopause 0 Polycystic ovaries 0 Schizophrenia 0 Premature death 0 Mental retardation FAMILY HISTORY FEMALE Paternal Ancestry Father s age (if living) Health Status: Paternal Grandfather s age (if living) Health Status: Paternal Grandmother s age (if living) Health Status: Parental Aunts and Uncles, Living Sex Age Health Parental Aunts and Uncles, Deceased Sex Age at Death Cause of Death Parental First Cousins, Sex Age Birth defect/cause of Death

4 New patient evaluation form Page 4 Maternal Ancestry Mother s age (if living) Health Status: Maternal Grandfather s age (if living) Health Status: Maternal Grandmother s age (if living) Health Status: Maternal Aunts and Uncles, Living Sex Age Health Maternal Aunts and Uncles, Deceased Sex Age at Death Cause of Death Maternal First Cousins, Sex Age Birth defect/cause of Death Brothers and Sisters Sex Age Health Deceased Siblings Sex Age at Death Cause of Death Children Sex Age Health Deceased Children Sex Age at Death Cause of Death

5 Infertility Evaluation Form Page 5 Please complete the following pages if applicable to your problem or you are seeking to become pregnant soon. INFERTILITY HISTORY How long have you been trying to become pregnant? years How often do you have intercourse? Usually times/wk. Do you douche before or after intercourse 0 Yes 0 No Is intercourse painful? 0 Yes 0 No Does your husband have problems with erection or ejaculation? 0 Yes 0 No Do you have problems with arousal or lubrication? 0 Yes 0 No PREVIOUS TESTING (check all tests that have been performed) 0 BBT (temperature chart) 0 Normal 0 Abnl 0 Laparoscopy 0 Normal 0 Abnl date 0 Day 3 FSH 0 Normal 0 Abnl date result 0 Immune Testing 0 Normal 0 Abnl date 0 Female Hormones 0 Normal 0 Abnl date 0 Chromosome Tests 0 Normal 0 Abnl date 0 Postcoital test 0 Normal 0 Abnl date 0 Semenanalysis 0 Normal 0 Abnl date 0 HSG (X-Ray) 0 Normal 0 Abnl date 0 Sperm Antibody 0 Normal 0 Abnl date 0 Endometrial biopsy 0 Normal 0 Abnl date My Blood Type Partner s Blood Type PREVIOUS TREATMENTS (check all previous treatments) 0 Laparoscopy (recent) dates Comments 0 Ectopic Pregnancy dates Comments 0 Tubal Reversal dates Comments 0 Clomid or Serophene dates Dose and number of month(s) treated 0 Fertinex/Humegon dates Dose and number of month(s) treated 0 Depot Lupron dates Dose and number of month(s) treated 0 Parlodel dates Dose and number of month(s) treated 0 Intrauterine Insemination Dates and number of month(s) treated 0 Intrauterine Insemination Dates and number of month(s) treated 0 Donor Sperm Dates and number of month(s) treated 0 Heparin & aspirin dates Dose and number of month(s) treated 0 IVIG dates Dose and number of month(s) treated 0 IVF/Donor egg dates Comments ADDITIONAL COMMENTS

6 Male Infertility Evaluation Form Page 6 PARTNER S PAST MEDICAL HISTORY List allergies to medications: List current medications: Do you have or have you had any of the following? (check all that apply) o AIDS or positive HIV o Thyroid problems o Anemia/thalassemia o Seizures/epilepsy o Ovarian cysts o Blood transfusions o Genetic disorder o Heart disease o Alcoholism o Endometriosis o Measles: regular o Birth defects o Varicose veins o Mental illness o Pelvic infection (PID) o Measles: German o Liver problems o Sickle cell or trait o Eating disorder o Herpes o Mononucleosis o Hepatitis o Lung disease o Depression o Gonorrhea o Mumps o Ulcers/colitis o Kidney infection o Drug addiction o Chlamydia o Tuberculosis o Gallbladder problems o Kidney stones o Arthritis o Ureaplasma infection o Diabetes (juvenile) o High blood pressure o Migraines o Lupus o Osteoporosis o Diabetes (pregnancy) o Rheumatic fever o Neurological problems o Abnormal Pap smear o Sexual abuse/rape Are you under a physician s care? 0 Yes 0 No If so, please give names and specify condition treated PREVIOUS MALE FERTILITY TREATMENTS (check all that apply) 0 Vasectomy reversal dates Comments 0 Fertility medications dates Comments 0 Varicocele surgery dates Comments FAMILY HISTORY MALE Paternal Ancestry Father s age (if living) Health Status: Paternal Grandfather s age (if living) Health Status: Paternal Grandmother s age (if living) Health Status: Parental Aunts and Uncles, Living Sex Age Health Parental Aunts and Uncles, Deceased Sex Age at Death Cause of Death Parental First Cousins, Sex Age Birth defect/cause of Death

7 Maternal Ancestry Mother s age (if living) Health Status: Maternal Grandfather s age (if living) Health Status: Maternal Grandmother s age (if living) Health Status: Maternal Aunts and Uncles, Living Sex Age Health Maternal Aunts and Uncles, Deceased Sex Age at Death Cause of Death Maternal First Cousins, Sex Age Birth defect/cause of Death Brothers and Sisters Sex Age Health Deceased Siblings Sex Age at Death Cause of Death Children with previous partner Sex Age Health Deceased Children Sex Age at Death Cause of Death

8 Reproductive Endocrinology and Infertility Group PATIENT AUTHORIZATION 1. As a center committed to providing the most up-to-date; effective reproductive treatment options for our patients, the physicians and embryologists at Reproductive Endocrinology and Infertility Group are often involved in research projects that contribute to advances in the field of reproductive endocrinology. In some cases, significant data associated with an individual patient's care may be included in a research publication or medical textbook though the information is always presented in an anonymous and confidential manner. I understand that as a patient at Reproductive Endocrinology and Infertility Group the results of my care may be included in research publications or textbooks but in no way will I be personally identified and this will not affect my course of treatment in any way. [Patient initial: /Partner initial: ] 2. I understand that test results may be shared with my spouse/partner unless I/we request otherwise. [Patient initial: /Partner initial: ] 3. I understand that due to HIPAA security regulations that were created to protect my privacy, unencrypted communication of Protected Health Information (PHI) is prohibited. I waive this right to protection in the circumstance where I, as a patient, initiate an communication with Reproductive Endocrinology and Infertility Group wherein by a response is expected. [Patient initial: /Partner initial: ] Patient name (print) Signature Date Partner name (print) Signature Date

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