Difficulty Conceiving? Yes No. Yes No. Yes No. Yes No

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Leslie Carroll
5 years ago
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1 FEMALE INFORMATION Name: _ Birth date: _ Total Number of Pregnancies: Occupation: Married Single Term births: Race: Height: ft inches Pre-term births: Religious Affiliation: Weight: pounds Miscarriages/Abortions: Nationality: _ Ectopic: How long have you been trying to achieve a pregnancy? months of unprotected intercourse How long have you been trying to achieve a pregnancy with current partner? months Date (Mo/Yr) Gender Current Partner? Months to Conception Please check here, if you have had more than five pregnancies. PREGNANCY INFORMATION Difficulty Conceiving? Fertility Treatment? Outcome Delivery Type _ MENSTRUAL CYCLE HISTORY (Answer these questions about your menstrual (bleeding) pattern). At what age did you begin having periods? years old When was the date of your last menstrual period? mm/dd/yyyy What is the average length of time your period lasts? days of flow What is the average length of time from the start of one period until the start of the next? days Within the last year, have your periods usually come (without medication) every days? If no, have your periods always been irregular? Do you ever have bleeding in between periods? Other: Other: Other: Other: Other: Do you currently need to take medication in order to get a period? Premarin Estrace Birth Control Pills Progesterone (if Progesterone, please specify type, below:) Provera Cycrin Aygestin Crinone Prometrium Other: Female Information Page: 1

2 Do you have pelvic pain with your periods? If yes, please indicate the level of pain that you usually experience: Mild Moderate Severe Do you often experience pelvic pain in between periods? If yes, do you take medication for pain? If yes, which one(s)? If yes, does the medication relieve pain? Have you ever used home ovulation predictor kits? If yes, what evidence for ovulation did you see? ( A positive test Color change Other: If yes, what day or range of days does it turn positive on? (Example: Day 14-15) Have you ever used any contraceptives? Birth Control Pills Injectable Hormones Hormone patch Intrauterine device (IUD) Tubal Ligation (Tubes tied) Other: Are you currently using any contraceptives? Birth Control Pills Injectable Hormones Hormone patch Intrauterine device (IUD) Tubal Ligation (Tubes tied) Other: Have you ever had a pap smear? If Yes, Is your pap smear current? When was the last pap done? mm/dd/yyyy Have you ever had an abnormal pap? If yes, what was the abnormality? Have you ever had a mammogram? GYNECOLOGIC HISTORY If Yes, Is your mammogram current? Yes If not, when was the last mammogram done? mm/dd/yyyy Do you have any breast discharge? Do you currently have acne? Do you have unwanted (facial, arm, chest, or other male pattern) hair growth that requires cosmetic removal? What is your sexual orientation? Heterosexual Homosexual Never been sexually active What is the number of sexual partners you have had in the past 2 years? Do you have a history of sexual abuse? If yes, have you received counseling Would you like us to make a referral for counseling? Do you often have pain with intercourse? How frequently do you have intercourse? per week Have you ever had any of the following procedures performed? Procedure Date (Mo/Yr) Findings Colposcopy (Follow up after an abnormal pap) Cryosurgery (destroy abnormal tissue by freezing) Cone Biopsy (removal of tissue from the cervix or cervix canal) Laser Treatment Leep Procedure Female Information Page: 2

3 Have you had any exposure to or have been treated for any sexually transmitted disease or pelvic infection? Gonorrhea Chlamydia Herpes Syphillis HIV/AIDS HPV (Human Papilloma Virus) MEDICAL HISTORY What is your blood type? Do you have long-standing medical conditions? If yes, please list: Medical Condition 5 Please check here, if you have more than five medical conditions. Have you ever needed or used thyroid medication? Synthroid Levoxyl Other: _ Comments/Findings Are you currently taking any medication? If yes, please list: Medications 5 Please check here, if you are taking more than five medications. Have you had the following vaccinations? Reason / Comments Vaccination Date (Mo/Yr) Vaccination Date (Mo/Yr) Measles Tuberculosis German Measles (Rubella) Polio Hepatitis A Tetanus Hepatitis B Influenza Chickenpox (Varicella) Are you allergic to or have had any adverse reaction to any drugs? If yes, please list: Medications 5 Please check here, if you are allergic to or have adverse reaction to more than five medications. Have you had any surgeries (other than Laparoscopy and hysteroscopy)? Note: Laparoscopy and Hysteroscopy questions are in the next page. Please do not enter them here. If yes, please list: Reaction / Comments (Mo/Yr) Indication Surgery Findings Complications 1 2 Female Information Page: 3

4 3 4 5 Please check here, if you have had more than five surgeries. Have you ever been diagnosed with HIV? Are you currently using acupuncture? Have you used acupuncture in the past? Do you currently smoke? How many cigarettes per day? # of cigarettes ENVIRONMENTAL FACTORS In the past, have you ever smoked? How much cigarettes per day on an average day # of cigarettes When did you quit? (Mo/Yr) Do you currently drink alcohol? How do you describe your drinking habits? Socially... drinks / week Daily... drinks / day Alcoholic... drinks / (how often?) In the past did you drink alcohol? Do you consume caffeinated beverages? If yes, on average, how many cups of coffee do you drink per day? 1-2 per day 3-4 per day More than 5 per day How many total of tea and/or soda? Do you currently use "recreational" drugs? If yes, What? _ Do you use herbal remedies or medications? If yes, What? How much per day? Are you on a special diet? Vegan? Vegetarian? Gluten free diet? Are you on any other kind of diet? Do you currently exercise? a. If yes, how many minutes on aversge do you exercise? b. On a scale of 1-10, what is the average lwevel of intensity of your entire workout? (1=low intensity, 5=moderate, 10=intense) c. What type of exercise do you usually participate in? GENETIC / FAMILY HISTORY Do you or anyone in your family have any of the following medical conditions? If yes, please check all that apply Medical Condition Self Mother Father Brother Sister Child Grand Mother Grand Father Early menopause (before age 45) Endometriosis Infertility Recurrent Miscarriage / Pregnancy loss Diabetes Mental Retardation - Chromosomal Testing Mental Retardation - Testing for Fragile X Mutation Birth Defects - Chromosomal testing Delayed puberty or pituitary tumor Female Information Page: 4

5 Breast Cancer Ovarian Cancer Cervical Cancer Uterine Cancer Bowel Cancer Colon Cancer Anemia Bleeding Disorder Autism Chromosome Disorder (e.g. Down s Syndrome) Muscular Dystrophy Hemophilia Huntington s Disease Polycystic Kidney Disease Neural Tube Defect Neurofibromatosis Marfan Syndrome Thyroid Disease Celiac Disease Hypertension Asthma Kidney Disease How old was your mother when her youngest and oldest child were born? years/ _ years Do you have a birth defect or familial disorder not listed above? If yes, Please describe? _ Have you or your significant other in this or any previous relationship had a stillborn child or more than two first trimester miscarriages? Ancestry (Mother) Ancestry (Father) Eastern European /Jewish Acestry Have you had Tay Sach s screening tests? (genetic condition most common in Jews of Eastern ancestry) If yes, when? (Mo/Yr). What were the findings? rmal Abnormal _ Pending Have you had a Canavan Screening Test? (Chromosome Study) If yes, when? (Mo/Yr). What were the findings? rmal Abnormal: _ Pending Have you had Bloom Screening Test? 9Chromosome Study) If yes, when? (Mo/Yr). What were the findings? rmal Abnormal: _ Pending Have you had Gaucher Screening Test? (Chromosome Study) If yes, when? (Mo/Yr). What were the findings? rmal Abnormal: _ Pending Have you had Fanconi Anemia Screening Test? (testing done for Bone Marrow Failure) If yes, when? (Mo/Yr). What were the findings? rmal Abnormal: _ Pending Have you had Neimman-Pick Screening Test? (Genetic testing) If yes, when? (Mo/Yr). What were the findings? rmal Abnormal: _ Pending African Ancestry Have you had Sickle Cell screening tests? (inherited blood disease) If yes, when? (Mo/Yr). What were the findings? rmal Abnormal: _ Pending European Ancestry or Family member with cystic fibrosis Have you been tested for Cystic fibrosis? If yes, when? (Mo/Yr). What were the findings? rmal Abnormal: _ Pending Italian, Greek, Mediterranean or Southeast Asian Ancestry Have you had screening for inherited forms of anemia such as thalassemia? Female Information Page: 5

6 If yes, when? (Mo/Yr). What were the findings? rmal Abnormal: _ Pending Have you had any of the following fertility tests in the past? INFERTILITY TESTS Ultrasound of the uterus and/or ovaries when NOT pregnant? If yes, when? (Mo/Yr) What were the findings? rmal Abnormal: _ Hysterosalpingogram (HSG)? An x-ray test of the uterus and tubes during which dye is injected into the uterus to see it If yes, when? _ (Mo/Yr) What were the findings? rmal uterus Abnormal uterus Both tubes open One tube blocked Both tubes blocked Other: Hysterosonogram (also called sonohysterogram)? An ultrasound test in which saline (salt water is injected and an ultrasound is used to see the uterus. If yes, when? (Mo/Yr) What were the findings? rmal uterine cavity Abnormal uterine cavity: _ Laparoscopy? A telescope is placed through the belly button to see inside your abdomen Date (Mo/Yr) Indication Surgery Findings Complications Please check here, if you have had more than three Laparoscopy tests. Hysteroscopy? A telescope is placed through the vagina into the uterus in order to see the inside of the uterus. Date (Mo/Yr) Indication Surgery Findings Complications Please check here, if you have had more than three Hysteroscopy tests. Other tests to specifically look at possible causes of infertility, miscarriage, or problems with menstrual cycle? Test Date (Mo/Yr) Results Day 3 FSH (Follicle Stimulating Hormone) Day 3 Estradiol Clomid Challenge Test (CCT) Day 3 FSH Clomid Challenge Test (CCT) Day 10 FSH Semen Analysis (Partner) Blood Test to verify ovulation Basal Body Temperature Chart (BBT) Endometrial Biopsy Inhibin Post Coital Test Anti-sperm antibodies (Female) Chromosome Analysis (Karyotype) - Female Chromosome Analysis (Karyotype) - Male Partner Anti-Phospholipid Antibodies Lupus-Anticoagulant TSH Prolactin LH Progestrone Female Information Page: 6

7 Test Date (Mo/Yr) Results Antmullerian Hormone (AMH) Factor V Leiden Mutation Prothrombin Mutation Testosterone Other PAST FERTILITY TREATMENTS Have you ever had any fertility treatments (e.g., Non medicated, Clomiphene Citrate, Gonadotropins, In- Vitro Fertilazation (IVF), Frozen Embryo, Gestational Surrogacy or Donor Egg Cycle)? If answer is no, skip all questions and screens on: o Clomiphene Citrate Cycle o Gonadotropins Cycle o In- Vitro Fertilization (IVF) Cycle o Frozen Embryo Cycle o Gestational Surrogacy o Donor Egg Cycle Have you ever had Non-Medicated IUI or Intercourse or Clomiphene Citrate (Clomid, Serophene) Cycle? If yes, please list the last three (most recent) IVF cycles information below: Mo/Yr Dose Monitoring Method of Sperm Delivery 1 pill = 50 mg 2 pills = 100 mg _ mg _ mg _ mg _ mg Sono= ultrasound None Ovulation kit Blood/Sono None Ovulation kit Blood/Sono None Ovulation kit Blood/Sono None Ovulation kit Blood/Sono IUI = insemination or placement of sperm into the uterus Intercourse Intercourse Intercourse Intercourse Please check here, if you have had more than four Clomiphene cycles. Complications Outcome? Delivery Type? Please explain OHSS = Ovarian Hyperstimulation Syndrome ovulation pregnancy ovulation pregnancy ovulation pregnancy ovulation pregnancy Other: Other: Other: Other: Female Information Page: 7

8 Have you ever had any Gonadotropins (Pergonal, Metrodin, Repronex, Humegon, Fertinex, Gonal-F, Follistim, Cetrotide, Antagon, Lupron) cycle? If yes, please list the last three (most recent) Gonadotropin cycles nformation below: Mo/Yr Dose (Amps/Vials per day) Medication No. of days Method of Sperm Delivery Intercourse Intercourse Intercourse Intercourse Please check here, if you have had more than four Gonadotropins cycles. Have you ever had any In-Vitro Fertilization (IVF) cycle? If yes, please list the last three (most recent) IVF cycles information below: Mo/Yr Egg source Medication Dose (Amps/Vials per day) Own Donor Own Donor Own Donor Own Donor ICSI? No. Inseminated Eggs Please check here, if you have had more than four Gonadotropins cycles. Number fertilized of eggs Transfer Day Complications Outcome? Delivery Type? Number of embryos transferred Numbe r frozen ovulation pregnancy ovulation pregnancy ovulation pregnancy ovulation pregnancy Outcome? _ ovulation pregnancy _ ovulation pregnancy _ ovulation pregnancy _ ovulation pregnancy Other: Other: Other: Other: Delivery Type? Other: Other: Other: Other: Female Information Page: 8

9 Have you ever had any Frozen Embryo cycle? If yes, please list the last three (most recent) Frozen Embryo cycles information below: Mo/Yr Natural or Medicated Cycle Transfer Day # Thawed # Survived # Transferred Outcome? Delivery Type? Natural Medicated Natural Medicated Natural Medicated Natural Medicated Please check here, if you have had more than four Frozen Embryo cycles. ovulation pregnancy _ ovulation pregnancy _ ovulation pregnancy _ ovulation pregnancy _ Have you ever had any Gestational Surrogacy or Donor Egg Cycles? If yes, what was the indication: _ Have you ever been an egg donor? Other: Other: Other: Other: Page: 9

Infertility History Form

Date form completed: Infertility History Form Patient s name: _ Age: Date of Birth: Occupation: Partner s name: Age: Date of Birth: Occupation: Prior marriage: Yes No # Prior marriage: Yes No # Attempted