NEW PATIENT HISTORY FORM

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Darrell Lynch
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1 Name: Clinic Number: Date of Birth: NEW PATIENT HISTORY FORM Date: Physician who referred you Fax: Would you like a letter sent? If yes, sign here DEMOGRAPHIC INFORMATION Name: Age: Date of Birth: Address: Occupation Home Phone Work Phone Partner s Name Age: Date of Birth: Partner s Occupation Partner s Phone: REASON FOR VISIT INFERTILITY HISTORY How long have you been trying to get pregnant? years months Have you attempted pregnancy prior to this relationship? Yes No If secondary (prior pregnancy), is this the same person who fathered your last child? Yes No Past Infertility Evaluation / Treatment Semen Analysis No Yes Result / date Endometrial Biopsy No Yes Result / date HSG (X-ray of tubes) No Yes Result / date Ovulation Predictor No Yes Result / date Laparoscopy No Yes Result / date Hysteroscopy No Yes Result / date Hormonal Tests: Prolactin No Yes Result / date TSH No Yes Result / date Day 3 FSH, Estradiol No Yes Result / date AMH No Yes Result / date Progesterone No Yes Result / date Clomiphene (Clomid) or Letrozole (Femara) Gonadotropins Prior Inseminations (IUIs) Prior in vitro fertilization (IVF) Location Date Dose Peak Estrogen # Eggs Retrieved % Fertilization (Embryos available) # Embryos Transferred, Stage Outcome Frozen Embryos? 1

2 PAST MEDICAL HISTORY (Please list any medical problems below) OBSTETRICAL HISTORY Date of Delivery Time to conceive Length of pregnancy (weeks) Gender Birth weight Outcome (e.g. miscarriage, ectopic, abortion, live birth) Pregnancy Complications GYNECOLOGIC and MENSTRUAL HISTORY Age of onset of periods Date of last menstrual period (LMP) Length of menses days Number of days between menses days/months How many pads/tampons do you use on the heaviest day of your period? Do you have pain during your period? If yes, does it affect your daily activities? Do you have pain between periods? Do you bleed between periods? Any history of any sexually transmitted diseases? Date and result of last Pap Smear Any history of abnormal Pap Smears? Have you had surgery or laser of the cervix? Date and result of last mammogram Do you have any problems with intercourse? Do you bleed during or after intercourse? Do you have pain during or after intercourse? In-utero exposure to DES (diethylstilbestrol) Have you used an IUD? Have you had a tubal ligation? IMMUNIZATIONS Have you had rubella (german measles) or a vaccine (MMR)? Date of vaccine Have you had varicella (chicken pox) or the vaccine? Date of vaccine SURGICAL HISTORY (Please list all surgeries including dates, hospitalization duration, and location) SOCIAL HISTORY Please circle one Married Widowed Separated Divorced Remarried Single Single In committed relationship How much caffeine do you drink per day? cups of coffee / tea / soda Do you smoke? Use any illicit substances? If yes, how much? for years How much alcohol do you drink per week? What kind? 2

3 MEDICATIONS (including complementary and alternative therapy, herbs, vitamins) 1. _Vitamin/Folate Yes No ALLERGIES EXERCISE Type Hours per week Days per week ETHNICITY (for genetic counseling purposes) Patient: Northern European African-American French Canadian Hispanic/Latino Jewish Mediterranean Partner (if applicable): Northern European African-American French Canadian Hispanic/Latino Jewish Mediterranean 3

4 REVIEW OF SYSTEMS Please mark any of the following disorders YOU currently have or have a history of: Central Nervous System Seizures Migraine Headaches Difficulty with memory ENT: Visual disturbances Sinus problems Cardiovascular: High blood pressure High blood pressure in pregnancy Chest pain Palpitations Dizziness History of Rheumatic Fever Heart valve disease Given prophylactic antibiotics Mitral valve prolapse Respiratory Shortness of breath Asthma Bronchitis Pneumonia Cough Tuberculosis Gastrointestinal Nausea/Vomiting Blood in stool Ulcers Hepatitis/Liver disease Diarrhea Constipation Psychiatric Anxiety Panic attacks Depression Eating disorders Gynecologic Bladder infections (cystitis) Incontinence Kidney infections Gonorrhea Chlamydia Herpes Syphilis Warts (HPV) Decreased sex drive Pelvic inflammatory disease (PID) Pelvic pain Endometriosis Breast discharge Hot flashes / Night sweats Musculo-Skeletal Rheumatoid arthritis Lupus erythematous Bone fractures Hematological Anemia Blood clotting disorder Bleeding tendency Sickle cell anemia or trait Endocrine Diabetes Diabetes in pregnancy Thyroid disease Heat or Cold intolerance (circle) Excessive hair growth Other: Rapid weight gain/loss (circle) Excessive thirst or hunger (circle) Acne/Skin Problems Constitutional Flu-like symptoms or fatigue Increase or decrease in appetite (circle) Weight gain or loss (circle) Fevers or chills Fatigue 4

5 FAMILY HISTORY Fill in the appropriate circles to identify all illnesses or conditions which you know have occurred in your blood relatives or partner. Partner Grandparents Daughters Sons Sisters Brothers Mother Father Self Uterine Cancer Colon Cancer/Rectal Cancer Colon Polyp Breast Cancer Prostate Cancer Ovarian Cancer Other Cancer Heart Defects Heart Disease Diabetes Asthma Dementia Tuberculosis (TB) Seizure Disorder Stroke/TIA High Cholesterol Abnormal Bleeding (Bleeding Disorder) Blood clots High blood pressure Anemia Endometriosis Hepatitis Liver disease Osteoporosis Alcohol Abuse Depression Eating Disorders Other Psychiatric/Mental illness Anesthesia complications Kidney disease Miscarriages Mental Retardation Down Syndrome Cystic Fibrosis Stillbirth Thalassemia/Sickle cell Cleft Lip or Palate, Spina bifida Tay Sachs, Guacher, Canavans Disease Neurofibromatosis Other 5

6 HUSBAND/PARTNER HISTORY Name: Birth date: Age Relationship duration Has husband/partner initiated a pregnancy in a previous relationship? If yes, please give outcome of pregnancy(live birth/ miscarriage, termination) Any pregnancy with birth defects/genetic disorder/stillbirth/ miscarriage? Has husband/partner had infertility in a previous relationship? Any history of the following? Prostatitis Epididymitis Orchitis Previous vasectomy Testicular tumor Injury to testes Undescended testicles Gonorrhea Chlamydia Syphilis Nonspecific urethritis Difficulty with erection Difficulty with ejaculation Exposure to radiation Exposure to chemicals Exposure to toxic substances Exposure to high temperatures HUSBAND/PARTNER MEDICAL HISTORY Weight Height PAST MEDICAL HISTORY (Please list any medical problems below) 3. PAST SURGICAL HISTORY (Please list any surgical procedures including dates and location) Social history How much caffeine does you partner drink per day? cups caffeine / tea / soda How many cigarettes does you partner smoke per day? cigarettes For how long? years How much alcohol does you partner drink per week? what kind Any illicit substances? MEDICATIONS (including supplements, hormones, steroids) Medication Reason Dates/Duration/Last time taken ALLERGIES 6

7 MD NOTES: See Electronic Medical Record for Further Detail Billing based upon: Multisystem Examination of total minute visit Consultation time/ management option discussed at length for: >60minutes ATTESTATION STATEMENT: I did or confirmed the history and physical examination, reviewed the checklists, and formulated the management plan. Signature Date / / Name PIC Time 7

NEW PATIENT FORM. PATIENT DEMOGRAPHIC INFORMATION Address City State Zip Your Occupation Home Phone Work Phone Other Phone. Who do you live with?

NEW PATIENT FORM. PATIENT DEMOGRAPHIC INFORMATION Address City State Zip Your Occupation Home Phone Work Phone Other Phone. Who do you live with? 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