Patient Past Medical History
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1 Patient Past Medical History A. Identifying Data Date this form when completed Your name Partner's name Age Birth date Height Weight Length of marriage (or relationship) How long have you been trying unsuccessfully to get pregnant? Have you previously been pregnant? Have you previously tried to get pregnant? Reason for your visit today? B. Pregnancy History Times pregnant Term births Premature births Miscarriages Elective abortion Adopted children 1. Date MisCarriage Elective abortions Ectopic Months to Conceive Infertility Treatment Weight & Sex C- Section Complication Is current partner the father C. Contraceptive Use Type From when to when Reason discontinued
2 D. Operations and Hospitalizations Date Diagnosis Operation Where performed Physician E. Medications: List all prescriptions and over the counter drugs used in the past year. Date Dosage and frequency From when to when Reason for taking F. Allergies To what (drug or substance) When what type of reaction? 2
3 G. Menstrual (hormonal) history Date your last menstrual period began Your age at your first period Are your periods regular? How many days from onset to onset? How many days do your period last? Do you bleed between periods? Do you always have premenstrual symptoms always rarely never? Vigorous exercise: Type hours/week Type hours/week If you have a hormonal disorder, please specify type and treatment Pelvic pain/cramps: none during your period before your period after your period at mid cycle during intercourse with urination with bowel movements cause you to miss usual activities cause you to miss work Pelvic pain/cramps are mild moderate severe getting worse improving not changing on the right side on the left side in the middle What medications do you take for pain/cramps? Do you have or have you had: Hot flashes Increased facial or body hair Breast discharge Increased acne Vision problems Weight gain (> 10 lb.) Poor sense of smell Weight loss (>10 lb.) Chronic headache Special dietary habits Head injury Vomiting Seizures Diabetes Thyroid disorder Autoimmune disease Excessive stress Psychiatric treatment If you answered yes to any question, please explain H. Physical Conditions/Infections Do you have, or have you had: Pelvic infection Appendicitis Chlamydia Colitis or enteritis Antichlamydial antibodies Endometriosis Gonorrhea Pelvic Adhesions Syphilis Uterine fibroids or myoma Mycoplasma Abnormal uterus (shape, ect.) 3
4 Urea plasma Ovarian cysts Tuberculosis Toxoplasmosis Cytomegalovirus I. Other GYN issues Do you have or have you had: Cervitis Recurring vaginitis Genital Herpes Abnormal pap smears Genital warts/ condyloma Cryo (freezing) or Trichomonas surgery of the cervix How many times a week do you have sexual intercourse? How many times do you have intercourse around ovulation? Do you use lubricants for intercourse? Do you douche before or after intercourse? Have you ever had unwanted sexual experiences? Do you have any sexual problems at this time? J. Partner medical history Your occupation Years of formal education Cigarettes--packs smoked/day Alcohol--type and number of drinks/week Marijuana--amount Other drugs--type and amount Ever used intravenous drugs? Caffeine drinks per day Radiation exposure Toxic Exposure Video display terminal--hours/day Electric blanket use Hot tub or sauna use List all serious or chronic illnesses or injuries not already described Do you or you family members have: infertility hormonal disorder other inherited disorders? If yes, please explain K. Partner's Medical History Your partner's age Occupation List all serious or chronic illnesses or injuries Medications Cigarettes--packs smoked/day Alcohol--type and number of drinks/week Marijuana--amount Other drugs--type and amount Ever used intravenous drugs? Caffeine drinks per day Radiation exposure Toxic exposure Video display terminal--hours/day 4
5 Electric blanket use Hot tub or sauna use Any problems with erection or ejaculation Has semen analysis ever been abnormal Has your partner seen a doctor for infertility evaluation? Doctor Diagnosis Treatment Has your partner ever fathered a pregnancy with another woman? Any inherited diseases in your partners family? Does your partner have or has he had: Chlamydia Vasectomy Antichlamydial antibodies Vasectomy reversal Gonorrhea Varicocele Syphilis Varicocele surgery Genital Herpes Biopsy of testicles Genital warts/condyloma Hernia surgery Mycoplasm Abdominal surgery Urea plasma Cancer Urethritis/epididymitis High blood pressure Prostatits Diabetes Penile discharge or pain Colitis Undescended testicle Seizures Injury to the testicle(s) Psychiatric treatment Mumps with injury to the testicles Excessive stress Physical abnormality Strenuous exercise DES exposure in womb Tight underwear L. Previous Evaluation Have you had: Not Result Approx. Values Done Normal Abnormal date (if known) Basal Body temperature (BBT) Urine LH surge Endometrial biopsy Blood tests: FSH LH Prolactin Thyroid tests (TSH, T4) DHEAS Testosterone Estradiol Progesterone Postcoital test Cervical Mucus penetration test Mycoplasma culture Chlamydia culture Antichlamydial antibodies Female antisperm antibodies Hysterosalpingogram (HSG) Ultrasound 5
6 IVP (kidney x-ray) Laparoscopy Hysteroscopy Karyotype Anticardiolipin antibodies Lupus anticoagulant Antinuclear antibodies (ANA) Coagulation screen Biochemistry/hematology panel Blood type Other Has your partner had: Semen analysis Hamster egg penetration assay Semen antisperm antibodies List all causes of infertility previously diagnosed M. Previous Treatment How many Dose Approx. dates Months? (If known) taken Antibiotics Clomiphene (Clomid, Serephene) hmg (Pergonal) HCG (Profasi) Progesterone Dexamethasone GnRH agonist (Synarel, Lupron) Danazol Intrauterine insemination Insemination with donor sperm IVF (in vitro fertilization) Gift Other Please use the remainder of this page to explain any additional information you feel we may need. If you have done IVF please obtain copies of the stimulation flow sheet and embryology lab data. 6
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