How did you hear about us?
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- Stuart Dorsey
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1 How did you hear about us? (please c all that apply) Physician referral Newspaper or Magazine Ad Radio Ad TV Ad Web Ad Web Search In the News please circle: print / TV / radio / online Friend or Family Member Other: (for instance: Duke Employee, yellow pages, brochure, driving by, etc)
2 Duke University Medical Center Division of Reproductive Endocrinology and Fertility Date: Female Fertility Initial Questionnaire & Medical History Intake Form Referring Physician Patient Name: SSN or History #: Date of Birth: Height: Weight: Race: Hispanic or Latino? Phone (day): Phone (night): Education level: Occupation: Marital Status: Partner Name: Partner SSN or Hx#: Partner DOB: Partner Race: Address: II. Pregnancy History How many Pregnancies (including abortions) have you had? 1 st Pregnancy When? (year) How long To conceive? (months) Fertility therapy used? Y/N Is current partner father? Y/N Duration of Pregnancy (months) Outcome* Complications 2 nd pregnancy 3 rd pregnancy 4 th pregnancy 5 th pregnancy *Outcomes: Vaginal Delivery=VD; Cesarean section=cs; Abortion=AB; Miscarriage=MS; Ectopic=EP III. Fertility History How long have you and your present partner been trying to conceive? Have you ever been infertile with a past partner? If so, How long? Have you had any of the following tests performed on you? Check all that apply and the results. Date Results Basal Body Temperature Urinary LH (Ovulation) Predictor Kits Postcoital Test Hormone Tests Endometrial Biopsy Patient History Intake Form Female Fertility Initial Questionnaire Page 1 of 5
3 Date Results Hysterosalpingogram (HSG) Sonohysterogram Ultrasound Antisperm Antibodies Laparoscopy Hysteroscopy Gonorrhea/Chlamydia Cultures Rubella (German Measles) Hepatitis B or C HIV RPR (Syphilis) Blood Type and Rh Antibody Screen What types of fertility therapy have you received in the past? Drug/Treatment Dose How long or how many cycles? When? Clomiphene citrate (Clomid, Seraphene) Gonadotropins (Pergonal, Repronex,Humegon, Metrodin, Fertinex, Gonal-F, Follistim) HCG (Profasi, Pregnyl) GnRH Agonists (Lupron, Zoladex, Synarel) Progesterone Prednisone or Dexamethasone Bromocriptine (Parlodel, Dostinex) Artificial Insemination Donor Insemination In Vitro Fertilization=ICSI IV. Gynecological History How old were you when you started having periods? Date your last period started Are your periods regular? If yes, how many days between periods (start until start)? If no, how many periods per year do you have? How many days do your periods last? Do you have cramps with your periods? If yes, are they: Mild Moderate Severe Have you ever missed work or school do to menstrual pains? Do you have pain with intercourse? Patient History Intake Form Female Fertility Initial Questionnaire Page 2 of 5
4 Where you ever diagnosed with endometriosis? What type of contraception have you used in the past? Birth Control IUD Depo Provera (birth control shots) Condoms Diaphragm Foams/Jellies Withdrawal Rhythm Tubal Ligation Contraceptive Complications: When did you last use contraception? Have you ever had an abnormal Pap smear? If so, when? What was done about it? When was your last Pap smear? Have you ever had any of the following (check all that apply): Gonorrhea Venereal Warts Syphilis Chlamydia Genital Herpes Pelvic Inflammatory Disease (PHD) Have you ever had an abnormal Mammogram? If so, when? What was done about it? When was your last mammogram? V. Medical History Do you have or have you ever had (check all that apply) Anemia Diabetes Ovarian cysts Appendicitis Gallbladder Problems Pneumonia Arthritis Heart Disease Rheumatic Fever Blood Transfusions hepatitis Rubella (German Measles) Breast Milky Discharge Hirsutism (Excess facial hair) Scarlet Fever Breast pain High Blood Pressure Seizures Chicken Pox or vaccination Kidney Infections Thyroid Problems Chronic Bronchitis Liver Problems Tuberculosis (TB) Chronic Headaches Migraine Headaches Ulcers Colitis Neurological problems Vision Problems Current Medications Are you allergic to any medications? What? Have you ever had surgery before? Date and type Patient History Intake Form Female Fertility Initial Questionnaire Page 3 of 5
5 VI. Social History Current or Recent Employer/Position Do you drink alcohol? Number of drinks per week Do you smoke? Number of cigarettes per day Number of years smoking Do you now, or have you ever, used illicit drugs (marijuana, cocaine, etc.)? Specify Do you have a special exercise program? Type Number of hours per week Are you on a special diet? Type VII. Review of Systems Have you had more than a 10 pound weight gain or loss in the past 12 months? Do you have problems with your vision (besides usual glasses), hearing, swallowing, sinuses or throat? Do you have heart problems, chest pain, irregular heart beat, or mitral valve prolapse? Do you have asthma, wheezing, shortness of breath or trouble breathing? Do you have breast pain, breast discharge, or a lump in your breast? Do you have chronic nausea or vomiting, stomach pain, diarrhea or constipation, blood in your stool or a history of ulcers? Do you have urinary burning, incontinence, kidney stones or blood in your urine? Do you have chronic joint or muscle pain or swelling? Do you have any chronic skin rashes or moles that have changed in size or appearance? Do you have changes in cold or hot tolerance, changes in skin tone or color, changes in your nails or body hair growth? Do you have any history of seizures, recurrent headaches or numbness in your extremities? If yes, specify: Do you have any symptoms of depression such as sadness, frequent crying or anger, emotional lability? If yes, specify: Patient History Intake Form Female Fertility Initial Questionnaire Page 4 of 5
6 VIII. Family History Did your mother take diethylstilbestrol (DES; a tablet given to women with a history of miscarriage or bleeding during pregnancy) when she was pregnant with you? Do any family members have significant health problems or inherited diseases? Check all that apply: Birth Defects Down Syndrome Muscular Dystrophy Brain/Spinal Defects Fragile X Syndrome Sickle Cell Disease Cancer Heart Disease Tay-Sachs Disease Cystic Fibrosis Hemophilia Thalassemia Diabetes High Blood Pressure Thyroid Disease Who? Are you from any of these ethnic backgrounds: (check all that apply) Italian Jewish Caucasian African American Other: Greek French Canadian/Cajun African Middle Eastern Hispanic Spanish Southern Chinese Asian Indian Taiwanese Filipino Southeast Asian If yes, have you had any specific genetic testing to see if you are a carrier of a genetic disease? IX. Additional Health Information Please bring this form with you to your first appointment. Ensure that records from your current or past physician have been sent or faxed to the address below at least one-week in advance of your visit. We look forward to meeting you. Patient History Intake Form Female Fertility Initial Questionnaire Page 5 of 5
7 Submitting Your Questionnaire to Duke Fertility Once you have completed the form fields above there are two ways to send us your completed information: 1) . Save this PDF to your computer with a unique name. i.e. Jane Doe s Questionnaire.pdf. Then this completed form as an attachment to pdcreic@mc.duke.edu 2) Print. Print the completed questionnaire and bring the form with you to your next appointment.
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