Name: Age: Date of birth: Who referred you to our care? Who is your OB/Gyn? FAX
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1 FEMALE PARTNER S EVALUATION Today s Date: Name: Age: Date of birth: Occupation: Partner s Name: Who referred you to our care? Who is your OB/Gyn? FAX THE MAIN PURPOSE OF TODAY S VISIT IS: (Please circle as many as apply) PHYSICIAN USE ONLY Total number of pregnancies 1. Infertility ( years) 9. Male infertility/ Low sperm count Full term (>37 weeks) 2. Blocked or damaged tube(s) / Tubes tied 10. Pelvic pain / Pelvic adhesions (scar tissue) Pre term(20 to 37 wks) 3. Amenorrhea (no periods) 11. In vitro fertilization (IVF) Miscarriage (<20 wks) 4. Polycystic ovaries (PCOS) 12. Recurrent pregnancy loss (miscarriages) Termination 5. Irregular menstrual cycles (irregular periods) 13. Pregnancy complication / Stillbirth Ectopic (tubal) 6. Hirsutism (excess facial/body hair) 14. Menorrhagia (heavy periods) Living children 7. Endometriosis 15. Premature menopause 8. Leiomyomata (fibroids) 16. Other (Specify) Have you been treated with these medications? (Please circle as many as apply) Provera, Medroxyprogesterone acetate Progesterone, Prometrium, Crinone Clomiphene, Serophene, Clomid hcg, Profasi, Pregnyl, Ovidrel, Novaryl Letrozole, Femara Bromocriptine, Cabergoline, Dostinex Gonal F, Follistim Lupron, Ganirelix, Cetrotide, Antagon Bravelle, Repronex, Menopur Synthroid, Levothyroxine Glucophage, Metformin, Avandamet Heparin, Lovenox, Aspirin 81mg, IVIG Other Have you ever had any of these treatments? (Please circle, and indicate number of treatments) Intrauterine insemination (IUI) In vitro fertilization (IVF) Embryo adoption Frozen embryo transfer (FET) Tubal / uterine surgery Donor sperm Donor egg Other YOUR PREGNANCY HISTORY (Please include ALL pregnancies) Blood Type? Year of How many months How long did the Who is the Any delivery or loss to get pregnant? pregnancy last? father? complications? Rev. 7/2015 APB 1 of 5
2 FERTILITY WORK-UP Have you had a hysterosalpingogram (HSG; x-ray dye test of the tubes)? Yes No Results: Have you had a sonogram (Ultrasound of the pelvis / uterus / ovaries)? Yes No Results: Have you had surgery in your abdomen or pelvis? Yes No Procedure: Procedure: Have you had surgery (Biopsy / cone / LEEP / cryo / freezing) on your cervix? Yes No Have you ever had an abnormal Pap smear? Yes No Date of your last pap smear: Was it normal? Yes No Have you ever had: (Circle as many as apply) Ovarian cysts or tumors Endometriosis Ectopic (tubal) pregnancies Scar tissue in your pelvis Uterine septum Scar tissue inside your uterus Uterine fibroids Uterine polyps Uterine birth defects Chlamydia Gonorrhea Pelvic inflammatory disease Other sexually transmitted infection (e.g., Herpes, genital warts, HPV, etc.) OVULATION ASSESSMENT Do you have regular, predictable, spontaneous menstrual periods? Yes No Age of your first period: How many days does your period last? How many days from the first day of one period to the first day of the next? Do you ever have spotting in between periods? If you do not have periods, when did they stop? Are your periods heavy, either now or in the past? Do you have premenstrual symptoms? Yes ( Cramps Breast pain Bloating Mood changes) No Do you have pain or cramps with your periods? Yes ( Mild Moderate Severe) No Do you have pelvic pain between your periods? Yes (With ovulation? ) No What medicine or action helps decrease the pain? What have you used for birth control? When did you stop? Have you ever taken medicine to start your periods? Yes ( What? ) No Do you have or have you ever had: (Please circle as many as apply) Blood test for: Progesterone FSH TSH (thyroid) Glucose Insulin Hemoglogin A1c Nipple discharge Hot flashes Night sweats Hair loss Acne Diabetes Thyroid disease Unwanted hair on Chin Sideburns Mustache Chest Abdomen What is your weekly exercise? What is your weight? Currently Ideally One year ago Five years ago Rev. 7/2015 APB 2 of 5
3 PAST MEDICAL HISTORY / SYSTEMS REVIEW (Please circle any conditions that you have or have had) High blood pressure Heart disease Stroke Mitral valve prolapse Lung disease / Asthma Cystic fibrosis Hepatitis Gallbladder disease Bowel disease Liver disease Blood in stool Skin disease Psychiatric disease Headaches Depression / Anxiety Neurological disease / seizures Urinary tract infections Kidney disease Blood in urine Cancer Bleeding disorder HIV infection Breast disease Vision or hearing defects Sickle cell anemia / trait Blood disease (Anemia) Diabetes Thyroid disease Other Surgeries or hospitalizations (Please give dates): Date of your last mammogram: Was it normal? Yes No (Explain ) Current Medications: (Please include dosage, frequency, and any over-the counter drugs, herbs, and vitamins) Food / Medication / Latex Allergies: Habits: Do you use tobacco? Yes ( cig/day; total # of years) No Are you a former smoker? Yes (Congratulations! When did you quit? ) No Do you drink alcohol? Yes (# of drinks/week: ) No Illicit drug use? Yes (Type? How often? ) No # of caffeinated drinks per day: FAMILY HISTORY Age Age at Death Medical or Pregnancy-Related Problems Mother: Father: Is she menopausal? Yes (What age? Did she have a hysterectomy? ) No Any cancer? Yes ( Breast Ovarian Colon Other ) No Any blood clots? Yes (Who, and where? ) No Any autoimmune diseases? Yes (Who, and what type? ) No Anyone with: Genetic or inherited diseases? Birth defects? Mental retardation? No Any medical diseases not listed? Yes (Who, and what type? ) No What is your ethnic background? Rev. 7/2015 APB 3 of 5
4 COUPLE S SEXUAL HISTORY How often do you and your partner have sexual intercourse? Do you time intercourse to ovulation? Yes ( Calendar Phone App Urine predictor kits Other) No Do you use any lubricants during intercourse? Yes (What kind? ) No Do you have any pain with intercourse? Yes ( ) No Do you have any other sexual difficulties as a couple? Yes (Please explain ) No HAVE YOU HAD 2 MISCARRIAGES? Yes (Please answer below) No (Please skip to next section) Genetic Factors: Have you had a karyotype (chromosome) test? Yes ( Result? ) No Has your partner had a karyotype test? Yes ( Result? ) No Have you had a karyotype test on a miscarriage? Yes ( Result? ) No Have you/your partner had any other genetic tests? Yes ( Result? ) No Immunologic Factors: Do you have an autoimmune disease (e.g. lupus, rheumatoid arthritis, etc) Yes No Have you had any abnormal immune tests? (Please circle as many as apply) No Positive syphilis test Lupus anticoagulant Anticardiolipin antibodies Antithyroid antibody PTT drvvt Antiphospholipid antibodies Rheumatoid factor Immunologic therapy Antinuclear antibodies Other immune tests (Describe ) Thrombophilic Factors: Do you have a history of blood clots? Yes ( ) No Have you been tested for: Factor V Leiden Factor II (prothrombin) MTHFR (Please circle as many as apply) Protein S Antithrombin Protein C Have you ever been on a blood thinner? Yes ( Heparin Lovenox Coumadin Baby aspirin) No Reason: MALE PARTNER S EVALUATION Not Applicable P NP Name: Date of Birth: Occupation: Name of urologist (if applicable): Any previous pregnancies? Yes (Year and Outcome ) No Has your sperm been tested? Yes ( Result? ) No Have you had a varicocele of the scrotum? Yes (Reason: ) No Have you seen a urologist for any reason? Yes (Reason: ) No Have you had: Genital surgery? Genital trauma? Genital infections? Hernias? No What health problems do you have? What medications / vitamins do you take? Do you : Smoke or use tobacco? Yes ( cig/day; total # of years) No Use alcohol? Yes (# of drinks/week: ) No Use illicit drugs? Yes (Type? How often? ) No Do you have allergies to any food, drugs, or latex? Yes ( ) No What diseases run in your family? Does infertility run in your family? Yes (Whom? ) No Rev. 7/2015 APB 4 of 5
5 PHYSICIAN USE ONLY: PHYSICAL EXAMINATION Height: Weight: BMI: kg/m 2 BP: RR: Temp: HEENT, incl. thyroid N AbN Skin, incl. hirsutism N AbN Neurological N AbN Heart / CV N AbN Respiratory N AbN Ext. Genitalia / Vagina / Cervix N AbN Adnexae N AbN Uterine size: Position: FEMALE DIAGNOSES: MALE DIAGNOSES: 1) CPT CPT 1) CPT 2) CPT CPT 2) CPT 3) CPT CPT 3) CPT 4) CPT CPT 4) CPT 5) CPT CPT 6) CPT CPT INFO/ADVICE LMP: Today is cycle day: Urine hcg Result: Start PNV / DHA MICRO: Chlamydia Mycoplasma Aero/Anaerob Culture Urine Analysis Urine C&S PCOS / Metformin GENERAL: PNS CBC CMP Platelet Iron Profile Sickle cell Screen LDH 25OH-Vitamin D3 Clomid / Letrozole REI: CD3 FSH/LH/E2 Random FSH/LH/E2 CD P4 AMH Quant hcg Gonadotropins ENDO: TSH PRL HgBA1C Fasting Insulin Free Testos Total Testos Lipid Profile DOR 8am Cortisol 17-OHP SHBG DHEAS CoQ10 / DHEA GENETIC: Karyotype- female FMR1 PCR CF mutation analysis Carrier Screening RPL ANATOMIC: HSG GYN USG DAY 3 USG Sonohysterogram Trial Transfer LSC/HSC IMMUNE: LAC APA anti-β2gp1 Anti-adrenal Anti-thyroid ANA anti-ds-dna APA/Heparin THROMB: Factor V Leiden Factor II MTHFR Prot C Act Prot S Act Antithrombin Lovenox IUI MALE: Semen analysis Sperm culture Retrograde analysis AS Ab Refer to Urology IVF ICSI PGT MALE ENDO: FSH LH PRL TSH Total T Free T Stop Smoking MALE STD: HIV I/II RPR Hepatitis B sag Hepatitis C Ab Weight Loss MALE GENETIC: Karyotype- male Y-chromosome microdeletions CF mutation analysis CryoBank Male Fertility Need HSG films/records from: Book OR: F/U Appt: Genetic Testing Donor Egg/Embryo Donor Sperm Meds Preg Categ Endometriosis Fibroids Decrease Caffeine Date Nurse/Resident MD Dictated Rev. 7/2015 APB 5 of 5
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