Questionnaire for Women

Transcription

1 Questionnaire for Women General Information Name Date Address Telephone Home _Work _ Cell Birth date Age _ Occupation Ethnic Background _ Height _ Weight _ Highest Education _ Partner s Name Marriage date _ Referred by: Gynecologic History Sexual History Age of first period _ Date of first day of last period _ Usual cycle length days range (interval from start of one period to start of next) Usual duration of bleeding Do you have any symptoms at time of ovulation (i.e., pain)? yes no Amount of flow Light Moderate Heavy Is cramping None Minimal Moderate Severe Circle symptoms preceding period: Frequency of sexual intercourse per week _ Use of lubricants yes no Name of lubricants Does partner ejaculate in the vagina during intercourse yes no Is intercourse painful to you? _ yes _no Is intercourse painful to your partner? _ yes _ no Contraceptive History None Breast soreness Irritability History of: Pelvic Pain Endometriosis Gynecologic surgery Last PAP Breast exam Mammogram Have you ever been treated for: Dates Syphilis Gonorrhea Chlamydia Genital warts Do you have a history of genital herpes yes no Did your mother take any medications while pregnant with you? _yes _no _don t know What? Was DES taken _ yes _ no Birth control pills yes no # of years taken _ Date stopped birth control pills Were menses regular before birth control pills yes no Were menses regular after stopping the pills yes no How long after stopping the pills did menses start Previous use of IUD (intrauterine device) yes no # years When was IUD removed (date) reason Circle previous use of: diaphragm condom foam rhythm sponge

2 Obstetrical History Have you been pregnant before? _ yes _ no Do you have children: _ yes _ no ages How long to conceive: RECORD ALL PREGNANCIES Pregnancy # Year Full term Preterm Miscarriage Terminations Complications Fertility Treatment Occupation/Leisure History Yes No Dates/Comments Exposed to chemical or x-rays in work or hobby _ Please list Amount per day or week Caffeine Smoking (history of or current use) Alcohol Marijuana Nutritional supplements, herbs, etc. Drugs Please describe recreational/sports activities (frequency, length of time, etc.) _ Family History Father s age if alive _ If no longer living, cause of death Medical problems: Mother s age if alive _ If no longer living, cause of death Age at menopause _ Medical problems: Sister(s) ages medical problems: Brother(s) ages medical problems: Is there a family history of: Yes No Comments Birth defects or genetic diseases Infertility Hormone problems Miscarriages/stillbirths Pregnancy problems Cancer Stroke Heart disease Lung disease Diabetes Thyroid/endocrine problems High blood pressure Blood clots (deep vein thrombosis, pulmonary embolism) Any women who have never menstruated Any men who have never had to shave Any additional comments you would like to make that you feel may be pertinent and have not already been addressed:

3 Medical/Surgery History Yes No Dates/Comments Mumps Measles Chicken Pox Rubella (German Measles) Rheumatic fever Elevated Blood pressure Blood clots (deep vein thrombosis, pulmonary embolism) Heart murmur Heart disease Diabetes Lung disease Liver or gall bladder disease Jaundice Kidney infections Hepatitis Kidney stones Gout Urinary tract abnormalities Thyroid disease Arthritis Auto immune diseases (lupus, rheumatoid arthritis, etc.) Other serious or chronic diseases Any surgery (list type and year) _ Do you have any allergies (medications, food, latex, iodine, contrast dye): Yes No If yes, list the specific allergies and reactions experienced: Please list any medications you are now taking or Current: _ Past: _ have taken in the past. Any history of therapeutic x-ray treatment or Current: _ Past: _ anti-cancer drugs? Have you ever been involved in psychotherapy or counseling? Yes No If yes, please indicate why, when, with whom, and any other pertinent information. _ Please fill in a review of any current or recent symptoms: Yes No Yes No Yes No Chronic headaches Increased thirst Excessive Fatigue History of head injury Increased sweating Tremors Convulsion history Intolerance to heat Desire for extra salt Visual problems Intolerance to cold Excess Loss of scalp hair Dizziness Difficulty swallowing Growth of hair on face Rapid weight change Change in voice or or body in new places Acne hoarseness Change in size of Change of appetite Difficulty sleeping clitoris Discharge from nipples

4 Pre-conceptual Health Screening Have you ever been tested for: Yes No If yes, give dates/results Hepatitis B _ HIV (AIDS) _ Rubella _ TB (Tuberculosis) _ Blood Type _ Tay-Sachs _ Gaucher Disease _ Canavan Disease _ Cystic Fibrosis _ Sickle cell _ Diabetes _ Anemia or Thalassemia _ Previous Infertility Testing Length of time currently attempting pregnancy Years Length of time not using contraceptives Months Yes No Year Normal Abnormal If yes, give dates/results Temperature charts Hysterosalpingogram (x-ray of tubes and uterus) Hysteroscopy (looking inside uterus) Endometrial biopsy (taking tissue from inside uterus) Post-coital test (to test sperm in cervical mucus) Semen Analysis Laparoscopy (looking inside the abdomen) Hormone Tests Day 3 FSH Day 3 Estradiol Clomid Challenge Test Thyroid tests Chromosome tests

5 Previous Infertility Treatment Treatment with Clomiphene (Clomid, Serophene) If Yes: Cycles without Intrauterine Insemination (IUI) #Cycles / Dates _ Cycles with Intrauterine Insemination (IUI) #Cycles / Dates _ Pregnant Dates _ Treatment with Gonadotropins (Follistim, Gonal-F, Bravelle, Menopur) If Yes: Cycles without Intrauterine Insemination (IUI) #Cycles / Dates _ Cycles with Intrauterine Insemination (IUI) #Cycles / Dates _ Pregnant Dates _ Treatment with IVF or other Reproductive Technologies (GIFT, ZIFT) Cycle # Protocol (if known) Dose of FSH or LH Estrogen Level at retrieval # Eggs Retrieved # Embryos Transferred Pregnant? Delivery? Other comments on infertility treatments: Please include any other information which you believe may be pertinent to your infertility problem _