PATIENT INTAKE HISTORY
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- Bartholomew O’Neal’
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1 PATIENT INTAKE HISTORY PATIENT INFORMATION NAME: PARTNER S INFORMATION NAME: ADDRESS: ADDRESS: DATE OF BIRTH: / / HOME #: ( WORK #: ( MAY WE CONTACT YOU AT WORK? MOBILE # ( NO EMPLOYER: PLEASE ANSWER & SIGN: MAY WE DISCUSS YOUR TEST RESULTS WITH YOUR PARTNER/SPOUSE? SIGNATURE: REFERRING PHYSICIAN/OB/GYN: DATE OF BIRTH: / / HOME #: ( WORK #: ( MAY WE CONTACT YOU AT WORK? MOBILE # ( EMPLOYER: PLEASE ANSWER & SIGN: MAY WE DISCUSS YOUR TEST RESULTS WITH YOUR PARTNER/SPOUSE? SIGNATURE: PRIMARY CARE PROVIDER: PREFERRED PHARMACY: ADDRESS: Page 1 of 9 C:\Documents and Settings\atedrow\Desktop\Infertility Patient Intake Form doc
2 If you are uncomfortable answering any questions, please leave them blank; you can discuss them with your doctor or nurse PERSONAL PAST HISTORY OF ILLNESSES MAJOR ILLNESSES ASTHMA YES (DATE) NO PHYSICIAN/NURSE NOTES PNEUMONIA/LUNG DISEASE TUBERCULOSIS HEART ATTACK/PROBLEMS HIGH BLOOD PRESSURE STROKE BLOOD CLOTS IN LUNGS OR LEGS KIDNEY INFECTIONS/STONES SEXUALLY TRANSMITTED DISEASE HIV/AIDS THYROID DISEASE DIABETES EATING DISORDERS DEPRESSION/ANXIETY ARTHRITIS/JOINT PAIN/BACK PROBLEMS COLLAGEN VASCULAR DISEASE (LUPUS) CANCER REFLUX/HIATAL HERNIA/ULCERS HEPATITIS/JAUNDICE/LIVER DISEASE GALLBLADDER DISEASE COLITIS/CROHN S DISEASE ANEMIA BLOOD TRANSFUSIONS MIGRAINE HEADACHES SEIZURES/CONVULSIONS/EPILEPSY OTHER INJURIES/ILLNESSES IF NONE CHECK HERE - REASON DATE OR YEAR HOSPITAL C:\Documents and Settings\atedrow\Desktop\Infertility Patient Intake Form doc Page 2 of 9
3 OPERATIONS/HOSPITALIZATIONS IF NONE CHECK HERE - SURGERY/REASON DATE OR YEAR HOSPITAL FAMILY HISTORY MOTHER: LIVING DECEASED CAUSE: AGE: FATHER: LIVING DECEASED CAUSE: AGE: SIBLINGS: NUMBER LIVING: NUMBER DECEASED: CAUSE(S)/AGES(S): CHILDREN: NUMBER LIVING: NUMBER DECEASED: CAUSE(S)/AGES(S): ILLNESS DIABETES STROKE BLOOD CLOTS IN LUNGS OR LEGS HEART DISEASE HIGH BLOOD PRESSURE HIGH CHOLESTEROL OSTEOPOROSIS (WEAK BONES) RECURRENT MISCARRIAGE INFERTILITY BIRTH DEFECTS BREAST CANCER COLON CANCER OVARIAN CANCER UTERINE CANCER OTHER YES WHICH RELATIVE(S) AND AGE OF ONSET PHYSICIAN/NURSE NOTES SOCIAL HISTORY PHYSICIAN/NURSE NOTES EVER SMOKE? YES NO CURRENT SMOKING: PACKS PER DAY: HOW MANY YEARS: IF YOU ARE CURRENTLY SMOKING, ARE YOU READY TO QUIT? YES NO ALCOHOL: DRINKS PER DAY: DRINKS PER WEEK: RECREATIONAL DRUG USE? YES NO HAVE YOU BEEN SEXUALLY ABUSED, THREATENED, OR HURT BY ANYONE? YES NO OCCUPATION/JOB: EDUCATION COMPLETED: HIGH SCHOOL SOME COLLEGE COLLEGE /BA DEGREE GRADUATE DEGREE OTHER C:\Documents and Settings\atedrow\Desktop\Infertility Patient Intake Form doc Page 3 of 9
4 OBSTETRIC HISTORY - IF NO PREGNANCIES PLEASE CHECK HERE - NUMBER NUMBER NUMBER PREGNANCIES ABORTIONS MISCARRIAGES PREMATURE BIRTHS (<37 WEEKS) LIVE BIRTHS LIVING CHILDREN # BIRTH DATE BIRTH WEIGHT SEX WEEKS PREGNANT TYPE OF DELIVERY (VAGINAL, CESAREAN, ETC.) COMPLICATIONS CURRENT MEDICATIONS IF NONE CHECK HERE - (Including hormones, vitamins, herbs, nonprescription medications) CURRENT MEDICATIONS DOSAGE WHO PRESCRIBED CURRENT MEDICATIONS DOSAGE WHO PRESCRIBED MEDICATION ALLERGIES or OTHER ALLERGIES IF NONE CHECK HERE - ALLERGY TYPE OF REACTION C:\Documents and Settings\atedrow\Desktop\Infertility Patient Intake Form doc Page 4 of 9
5 PERSONAL PROFILE MARITAL STATUS: MARRIED LIVING WITH PARTNER SINGLE WIDOWED DIVORCED SEPARATED NUMBER OF PRIOR MARRIAGES FOR YOU AND PARTNER: HOW LONG HAVE YOU BEEN MARRIED OR LIVING WITH CURRENT PARTNER? SEXUAL ORIENTATION: HETEROSEXUAL HOMOSEXUAL BISEXUAL HYSTEROSALPINGOGRAM? SALINE SONOHYSTEROGRAM? LAPAROSCOPY? SEMEN ANALYSIS? HORMONAL STUDIES? YES INFERTILITY TESTING AND TREATMENT IF YES, NO PHYSICIAN/NURSE NOTES DATE OR YEAR FERTILITY MEDICATIONS TAKEN: CLOMID OVIDREL FSH/hMG LUPRON OTHER INFERTILITY TREATMENTS: IUI IVF ICSI DONOR EGGS DONOR SPERM OTHER GYNECOLOGIC HISTORY LAST NORMAL MENSTRUAL PERIOD (FIRST DAY): AGE PERIODS BEGAN: HOW OFTEN DO YOU GET PERIODS: LENGTH OF YOUR PERIOD (NUMBER OF DAYS OF BLEEDING): PHYSICIAN /NURSE NOTES YES NO PHYSICIAN/NURSE NOTES ANY RECENT CHANGES IN YOUR PERIODS? ARE YOUR PERIODS HEAVY? DO YOU BLEED BETWEEN PERIODS? DO YOU BLEED AFTER INTERCOURSE? DO YOU HAVE PAINFUL PERIODS? HAVE YOU HAD A SEXUALLY TRANSMITTED DISEASE? HAVE YOU HAD PELVIC INFLAMMATORY DISEASE (PID)? DATE OF YOUR LAST PAP TEST: WAS IT NORMAL? HAVE YOU EVER HAD AN ABNORMAL PAP TEST? DO YOU HAVE PELVIC PAIN? DO YOU HAVE ENDOMETRIOSIS? DO YOU HAVE FIBROIDS? DO YOU HAVE PAIN WITH INTERCOURSE? PREVIOUS METHOD(S) OF BIRTH CONTROL: BIRTH CONTROL PILLS IUD DEPO PROVERA NUVARING TUBAL LIGATION VASECTOMY CONDOMS C:\Documents and Settings\atedrow\Desktop\Infertility Patient Intake Form doc Page 5 of 9
6 ENDOCRINE HISTORY YES NO PHYSICIAN/NURSE NOTES HAS YOUR WEIGHT CHANGED? DO YOU HAVE EXCESS HAIR GROWTH? DO YOU HAVE ACNE? DO YOU HAVE NIPPLE DISCHARGE? DO YOU HAVE HOT FLASHES? DO YOU HAVE A HISTORY DES EXPOSURE? IMMUNIZATIONS - IF NONE CHECK HERE - HAVE YOU BEEN VACCINATED FOR: YES NO DATE OR YEAR PHYSICIAN S/NURSE NOTES RUBELLA (GERMAN MEASLES) VARICELLA (CHICKEN POX, SHINGLES) HAVE YOU HAD CHICKEN POX OR SHINGLES? WHAT IS YOUR BLOOD TYPE? REVIEW OF SYSTEMS Please check (x) if any of the following symptoms apply to you now or since adulthood If you are not sure, please put a (?) next to the symptom CONSTITUTIONAL FEVER EYES DOUBLE VISION VISION CHANGES GLASSES/CONTACTS SPOTS BEFORE EYES EAR, NOSE, AND THROAT MOUTH SORES CARDIOVASCULAR CHEST PAIN OR PRESSURE DIFFICULTY BREATHING ON EXERTION SWELLING OF LEGS RAPID OR IRREGULAR HEARTBEAT RESPIRATORY WHEEZING/ASTHMA SPITTING UP BLOOD SHORTNESS OF BREATH CHRONIC COUGH GASTROINTESTINAL FREQUENT DIARRHEA BLOODY STOOL NO NOW PAST PHYSICIAN/NURSE S NOTES C:\Documents and Settings\atedrow\Desktop\Infertility Patient Intake Form doc Page 6 of 9
7 NAUSEA/VOMITING/INDIGESTION CONSTIPATION INVOLUNTARY LOSS OF GAS OR STOOL GENITOURINARY BLOOD IN URINE PAIN WITH URINATION FREQUENT URINATION MUSCULOSKELETAL MUSCLE WEAKNESS MUSCLE OR JOINT PAIN SKIN RASH SORES MOLES BREASTS LUMPS NEUROLOGIC DIZZINESS SEIZURES NUMBNESS SEVERE MEMORY PROBLEMS FREQUENT OR SEVERE HEADACHES DEPRESSION OR FREQUENT CRYING SEVERE ANXIETY WOULD YOU LIKE A REFERRAL TO A COUNSELOR? ENDOCRINE HAIR LOSS DIABETES HEAT OR COLD INTOLERANCE ABNORMAL THIRST HEMATOLOGIC/LYMPHATIC FREQUENT BRUISES CUTS THAT DO NOT STOP BLEEDING ENLARGED LYMPH NODES (GLANDS) C:\Documents and Settings\atedrow\Desktop\Infertility Patient Intake Form doc Page 7 of 9
8 PARTNER S INTAKE HISTORY NAME: DATE OF BIRTH: OCCUPATION/JOB: IF MALE PARTNER PLEASE COMPLETE THE FOLLOWING: DID YOU HAVE CHILDREN BY PREVIOUS WIFE OR PARTNER? HAVE YOU EVER SEEN AN UROLOGIST? WERE YOU BORN WITH UNDESCENDED TESTICLES? HAVE YOU EVER HAD CHLAMYDIA OR GONORRHEA? HAVE YOU HAD SIGNIFICANT RADIATION EXPOSURE? HAVE YOU HAD SIGNIFICANT PESTICIDE OR TOXIC SOLVENT EXPOSURES? DO YOU SUFFER ANY CHRONIC ILLNESSES? HAVE YOU HAD A RECENT (PAST 12 MONTHS) ACUTE ILLNESS? HAVE YOU HAD DOUBLE VISION, LOSS OF VISION, BREAST ENLARGEMENT, OR LOSS OF SEX DRIVE? DID PUBERTY OCCUR AT A NORMAL AGE AS A TEENAGER? YES NO PHYSICIAN/NURSE S NOTES GIVE ROUGH ESTIMATE OF SEXUAL FREQUENCY: MONTHLY: WEEKLY: PARTNER MEDICATIONS IF NONE CHECK HERE - (Including vitamins, herbs, nonprescription medications) CURRENT MEDICATIONS DOSAGE WHO PRESCRIBED CURRENT MEDICATIONS DOSAGE WHO PRESCRIBED YES NO PHYSICIAN/NURSE S NOTES HAVE YOU RECENTLY (PAST 18 MONTHS) USED ANY OF THE FOLLOWING DRUGS? DILANTIN (FOR SEIZURES USUALLY)? AZULFIDINE (FOR CROHNS DISEASE OR ULCERATIVE COLITIS)? STEROIDS: CORTISOL, PREDNISONE, HYDROCORTISONE? MARIJUANA? BODY BUILDING MEDICATIONS OR SUPPLEMENTS? KETOCONAZOLE FOR FUNGAL INFECTIONS? PARTNER OPERATIONS/HOSPITALIZATIONS IF NONE CHECK HERE - SURGERY/REASON DATE OR YEAR HOSPITAL C:\Documents and Settings\atedrow\Desktop\Infertility Patient Intake Form doc Page 8 of 9
9 PARTNER FAMILY HISTORY MOTHER: LIVING DECEASED CAUSE: AGE: FATHER: LIVING DECEASED CAUSE: AGE: SIBLINGS: NUMBER LIVING: NUMBER DECEASED: CAUSE(S)/AGES(S): CHILDREN: NUMBER LIVING: NUMBER DECEASED: CAUSE(S)/AGES(S): ILLNESS YES WHICH RELATIVE(S) PHYSICIAN/NURSE NOTES INFERTILITY BIRTH DEFECTS OTHER C:\Documents and Settings\atedrow\Desktop\Infertility Patient Intake Form doc Page 9 of 9
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