AMERICAN SOCIETY FOR REPRODUCTIVE MEDICINE Infertility History Form

Transcription

1 AMERICAN SOCIETY FOR REPRODUCTIVE MEDICINE Infertility History Form IMPORTANT: Please complete this form and bring it with you to your scheduled visit. This form was developed by the American Society for Reproductive Medicine to assist physicans and patients in obtaining a complete infertility history. It consists of three parts: Part I: Part 2: Part 3: Contact Information Your Medical History Your spouse/male partner's medical history (if applicable) FOR OFFICE USE ONLY PART I: CONTACT INFORMATION First Name Middle Initial Last Name Age Indicate which number to call or leave messages. o Home o Work o Cell Spouse/Male Partner's First Name Middle Initial Last Name Age Indicate which number to call or leave messages. o Home o Work o Cell Who Referred You? o Physician Name Phone Address Physician Notes (for office use only) o Former Friend / Patient o Web Site o Insurance (Name of Insurance) Who is your Ob / Gyn? Name Phone Address Who is your Primary Care Physician? Name Phone Address PART II : FEMALE MEDICAL HISTORY AND INFORMATION Reason for Visit: o Infertility Evaluation o Sperm Insemination o Other What are your expecations for this visit? What questions do you want answered at this visit? Do you have any personal, ethical, or religious objections to any of our tests or treatments such as insemination, in vitro fertilization, egg donation, sperm donation, masterbation to collect semen sample, etc.? o No o Yes How many months have you been having intercourse without using any form of birth control? Page 1

2 Pregnancy Summary Total Number of ALL Pregnancies: Number of Miscarriages (less than 20 weeks): Number of Ectopic / Tubal Pregnancies: Number of Elective Terminations (Abortions): _ Number of Full Term Deliveries: Of these, how many were live births? How many were still born? Number of Premature (less than 37 weeks) Deliveries: Of these, how many were live births? How many were still born? Any pregnancies with Birth Defects? o No o Yes - explain _ Date Pregnancy Months to Treatments to Delivery Type/D&C/ Current Ended or Delivered Conception Conceive Complications Partner? 1. o Y o N 2. o Y o N 3. o Y o N 4. o Y o N 5. o Y o N 6. o Y o N Menstrual History Menstrual cycle pattern (check all that apply): o Regular periods o Irregular periods o Spotting between o No periods o Heavy periods o Light Periods o Bleeding between periods Number of days between the start of one period to the start of the next period: days How many days of bleeding do you have? days Date of the 1st day of your last 2 mentrual periods: / / ; / / Age when you had your first period: years old How many periods do you have per year? Do you need medication to bring on a period? oyes: - what type? _ o No If you do not have periods, at what age did you stop having them? years old Do you have severe cramping or pelvic pain with your periods? oyes: Always Sometimes Recently In the past o No Contraceptive History o None o Condoms - dates of use o Diaphram - dates of use o IUD - dates of use _ o Birth control pills - dates of use - complications? o Never used birth control pills o Injectable contraception (Depo-Provera, Lunelle, etc.) - dates of use - complications? o Skin patch - dates of use - complications? o Foam or Jelly o Tubal sterilization procedure (tubes tied) - date (month/year) o Tubes untied - date (month/year) / Did your mother take DES when she pregnant with you? o Yes o No o Don't Know Sexual History How many times do you have intercourse per week? _ times per week o None o Not applicable Have you used over-the-counter ovulation kits to time intercourse? o Yes o No Do you have pain with intercourse? o Yes o No Do you use lubricants (K-Y Jelly, etc.) during intercourse? o Yes - what types? o No Have you had any of the following sexually transmitted diseases or pelvic infections? o Yes (check all that apply) o No o Chlamydia - date o Gonorrhea - date o Herpes - date o Genital warts/hpv - date o Syphilis - date o HIV/AIDS - date ohepatitis - date o Other - date Pap Smear History When was your last pap smear (month and year)? / o Normal o Abnormal When was your last abnormal pap smear? o Not applicable Have you undergone any procedure as a result of an abnormal pap smear? o Yes (check all that apply) o No o Colposcopy o Cryosurgery (Freezing) o Laser treatment o Conization o LEEP procedure Page 2

3 Breast Screening History Have you ever had a mammogram? o No o Yes - date Result: o Normal o Abnormal - explain Do you perform breast self exams? o Yes o No Medical History Are you allergic to any medications? o No o Yes (Please list and describe reactions) Are you allergic to any foods (peanuts, eggs, etc.)? o No o Yes (Please list and describe reactions) List any medications you are currently taking, including over-the-counter medicines Do you take any herbal medicines/vitamins or health food store suplements? o No o Yes (Please list) Do you have any medical problem(s) o No o Yes (Please list type, dates and treatments) (1) _ (2) _ (3) _ (4) _ (5) _ Did you have either of these childhood illnesses? o Chickenpox (Varicella) o German Measles (Rubella) o Don't Know Other childhood diseases: Vaccinations Chickenpox (Varicella) o No o Yes (dates ) o Don't Know MMR - Measles, Mumps, and Rubella (German measles): o No o Yes (dates ) o Don't Know BCG (Tuberculosis): o No o Yes (dates ) o Don't Know Hepatitis B: o No o Yes (dates ) o Don't Know Polio: o No o Yes (dates ) o Don't Know Hepatitis A: o No o Yes (dates ) o Don't Know Tetanus: o No o Yes (dates ) o Don't Know Influenza o No o Yes (dates ) o Don't Know Social History How many caffeinated beverages (coffee, tea, soda) do you drink per day? o None Do you smoke cigarettes? o No o Yes How many/day? How many years? Quit - when? Do you drink alcohol? o No o Yes o Beer - # per week o Wine - # per week o Liquor - #per week Do you use marijuana, cocaine, or any other similar drugs? o No o Yes (describe ) Do you exercise? o No o Yes (describe ) Are you aware of any radiation exposure other than X-rays? o No o Yes (describe ) Physician Notes (for office use only) Page 3

4 Surgical History Have you had any surgeries? o No o Yes (List all surgeries in chronological order.) Year Reason and Type of Surgery (1) _ (2) _ (3) _ (4) _ (5) _ (6) _ (7) _ Did you have any anesthesia problems? o No o Yes (describe) ) Physical Symptoms General: Head, Eyes, Ears, Nose and Throat: Respiratory: o Recent weight gain or loss o Dizziness o Loss of sense of smell o Shortness of breath o Anorexia / Bulimia o Headaches ochronic nasal congestion o Asthma o Bronchitis o Lack of energy o Blurred Vistion o Ringing Ears o Pneumonia otuberculosis o Fever/Chills o Hearing loss/deafness o Bloody cough o Other o Other o Other o None o None o None Endocrine/Hormonal: Breasts: Neurological Problems: o Diabetes o Hair loss o Discharge (clear? bloody? milky? ) o Weakness/Loss of balance o Thyroid gland problems o Lumps o Pain o Cancer o Seizures/Epilepsy o Rapid weight gain or loss o Abnormal mammogram o Headaches o Excessive hunger/thirst o Reduction o Migraine headaches o Temperature intolerance o Augmentation / Breast implants o Numbness hot flashes or feeling cold (saline? silicone? ) o Memory Loss o Other o Other o Other o None o None o None Gastrointestinal: Genito-Urinary: Skin/Extremities: o Nausea/Vomiting o Ulcers o Bladder infections o Unexplained rash/inflammation o Hepatitis o Diarrhea o Kidney infections o Acne o Blood in your stool o Constipation o Vaginal infections o Skin cancer o Irritable Bowel Syndrome o Frequent urination o Leaking urine o Burn injury o Change in bowel habits o Blood in the urine o Moles changing in appearance o Colitis (ulcerative or Crohn's) o Herpes o Excess hair growth o Other o Other o Other o None o None o None Musculoskeletal: Hematologic: Cardiovascular: o Unusual muscle weakness o Blood clotting disorder/blood clot o Palpitations/Skipped beats o Decreased energy / stamina o Sickle cell Anemia o Thrombophlebitis o Chest Pain o Heart attack o Rheumatiod arthritis o Easy Bruising o Stroke o Murmurs o Lupus Erythematosus o Swollen glands/lymph nodes o High blood pressure o Myasthenia gravis o Blood transfusions (dates/reasons ) o Rheumatic fever o Other o Other o Mitral valve prolapse (need antibiotics o None o None before dental procedures? Yes No o Other Mental Health Problems: o None o Depression o Anxiety Disorder o Schizophrenia Physician Notes (for office use only) o Other o None Page 4

5 Family History Living Cause of Death/Age at Death Mother oyes-age o No _ What is your Ancestry? Father oyes-age o No _ o African - American Brother(s) oyes-age o No _ o American Indian/Native American oyes-age o No _ o Ashkenazi Jewish Sister(s) oyes-age o No _ o Asian - American oyes-age o No _ o Cajun/French Canadian Maternal Grandmother oyes-age o No _ o Caucasian Maternal Grandfather oyes-age o No _ o Eastern European Paternal Grandmother oyes-age o No _ o Hispanic/Caribbean Paternal Grandfather oyes-age o No _ o Northern European o Southern European Disorders in Your Family o Other (specify ) Relationship to you Breast Cancer o Yes o No o Don't Know Would you like to be screened for: Ovarian Cancer o Yes o No o Don't Know o Cystic Fribrosis: Y N Colon cancer o Yes o No o Don't Know o Sickle Cell Anemia: Y N Diabetes o Yes o No o Don't Know o Tay-Sachs Disease: Y N Thyroid Problems o Yes o No o Don't Know o Thalasemia: Y N Heart disease o Yes o No o Don't Know Blood clots o Yes o No o Don't Know Obesity o Yes o No o Don't Know Psychiatric Problems o Yes o No o Don't Know Tuberculosis o Yes o No o Don't Know Endometriosis o Yes o No o Don't Know Infertility o Yes o No o Don't Know Menopause before age 40 o Yes o No o Don't Know Birth defects o Yes o No o Don't Know Cystic Fibrosis o Yes o No o Don't Know Tay-Sachs disease o Yes o No o Don't Know Canavan disease o Yes o No o Don't Know Bloom syndrome o Yes o No o Don't Know Gaucher disease o Yes o No o Don't Know Niemann-Pick disease o Yes o No o Don't Know Fanconi Anemia o Yes o No o Don't Know Familial Dysautonia o Yes o No o Don't Know Muscular Dystrophy o Yes o No o Don't Know Neurologic (brain/spine) o Yes o No o Don't Know Neural Tube Defects o Yes o No o Don't Know Bone/Skeletal Defects o Yes o No o Don't Know Dwarfism o Yes o No o Don't Know Developmental delay o Yes o No o Don't Know Learning problems o Yes o No o Don't Know Polycystic kidney disease o Yes o No o Don't Know Heart defect from birth o Yes o No o Don't Know Down syndrome o Yes o No o Don't Know Other chromosome defects o Yes o No o Don't Know Marfan syndrome o Yes o No o Don't Know Hemophilia o Yes o No o Don't Know Sickle Cell Anemia o Yes o No o Don't Know Thalassemia o Yes o No o Don't Know Galactosemia o Yes o No o Don't Know Deafness/Blindness o Yes o No o Don't Know Color Blindness o Yes o No o Don't Know Hemochromatosis o Yes o No o Don't Know o None of the above o Other (Specify) Page 5

6 PRIOR INFERTILITY TESTING AND TREATMENT Have you had prior infertility testing or treatment elsewhere? o No o Yes Prior Tests (check all that apply): o Basal body temperature chart (date /results_) o Thyriod test (date /results ) o Ovulation test kit (date /results) o Day 3 blood test for FSH level (date /results_) o Hysterosalpingogram (HSG) (date /results ) o Laparoscopy surgery (date /results ) o Hysteroscopy surgery (date /results ) o Progesterone blood test (date /results ) o Prolactin blood test (date /results ) Prioe Treatment (check all that apply): # of cycles Dates (mo/year) (mo/year) Outcome o Intrauterine insemination: From / to / Pregnant: Delivered Ectopic Miscarriage; Not Pregnant o Clomiphene citrate with timed intercourse From / to / Pregnant: Delivered Ectopic Miscarriage; Not Pregnant maximum # tablets per day? o Clomiphene citrate with insemination: From / to / Pregnant: Delivered Ectopic Miscarriage; Not Pregnant maximum # tablets per day? o Daily fertility drug injections w/ insemination From / to / Pregnant: Delivered Ectopic Miscarriage; Not Pregnant maximum # vials per day? o Comleted in vitro fertilization cycle(s): From / to / Pregnant: Delivered Ectopic Miscarriage; Not Pregnant 1. # eggs #embryos transferred #frozen 2. # eggs #embryos transferred #frozen 3. # eggs #embryos transferred #frozen 4. # eggs #embryos transferred #frozen o Frozen embryo transfers: From / to / Pregnant: Delivered Ectopic Miscarriage; Not Pregnant 1. # embryos transferrred 2. # embryos transferrred 3. # embryos transferrred 4. # embryos transferrred Canceled in vitro fertilization attempt(s): From / to / Pregnant: Delivered Ectopic Miscarriage; Not Pregnant o Any other prior treatments (describe): Additional Information/Complications: Emotional Status On a scale of 1-10 (10 being the worst), estimate the level of stress you feel due to infertility and other pressures. Do you see a counselor? o No o Yes - For how long? How often? List any antidepressant/antianxiety medications you are currently taking. Describe any emotional, marital or sexual problems caused by your infertility. PATIENT'S SIGNATURE DATE I confirm that I have reviewed the information above. PHYSICIAN'S SIGNATURE_ DATE Page 6

7 PART III: MALE MEDICAL HISTORY AND INFORMATION Complete with your male partner if applicable. Have you ever been evaluated by a urologist? o Yes o No Have you previously conceived with another woman? o Yes: How many times? o No: Birth control used? Yes No Have you had a semen analysis? o Yes o No Do you have difficulty with erections? o Yes o No Do you have retrograde ejaculation of sperm into the bladder? o Yes o No Have you had any of the following sexually transmitted diseases or pelvic infections? o Yes (check all that apply) o No o Chlamydia - date o Gonorrhea - date o Herpes - date o Genital warts/hpv - date o Syphilis - date o HIV/AIDS - date ohepatitis - date o Other - date Have you had a history of undescended testitcles? o Yes - One side Both o No Do you have scrotal or testicular pain? o Yes o No Did you have the mumps after puberty? o Yes o No Have you had prior injury to your testicles requiring hospitalization o Yes o No Have you been diagnosed with any of the following diseases? o Diabetes Mellitus - Yes No o Multiple Sclerosis - Yes No o Prostatic infections - Yes No o High blood pressure - Yes No o Cancer - Yes No o Other neurologic problems - Yes No o Urinary infections - Yes No If yes, any medications? Have you had any fever in the last 3 months? o Yes o No Have you had a vasectomy? o Yes (date ) o No If yes, have you had a vasectomy reversal? o Yes (date ) o No Have you had surgery for varicocele repair? o Yes o No Have you had hernia surgery? o Yes o No Did you undergo any bladder or penis surgery as a child? o Yes o No Are you exposed to prolonged heat in the workplace? o Yes o No Are you exposed to any radiation or harmful chemicals in the workplace? o Yes o No Have you had chemotherapy for cancer? o Yes o No Are you allergic to any medications? o No o Yes (Please list and describe reactions) List your current medications: List any current medical problem(s): How many caffeinated beverages to you drink per day? o None Do you smoke cigarettes? o No o Yes How many/day? How many years? Quit - when? Do you drink alcohol? o No o Yes o Beer - # per week o Wine - # per week o Liquor - #per week Do you use marijuana, cocaine, or any other similar drugs? o No o Yes (describe ) Do you exercise? o No o Yes (describe ) Are you aware of any radiation exposure other than X-rays? o No o Yes (describe ) Do you use hot tubs regularly? o No o Yes Did your mother take DES during pregnancy to prevent miscarriage? o Yes o No o Don't Know Have any of your immediate family members had difficulty conceiving a child? o Yes o No If yes, please describe: Physician Notes (for office use only) Page 7

8 Disorders in Your Family Relationship to you What is your Ancestry? Cystic Fibrosis o Yes o No o Don't Know o African - American Tay-Sachs disease o Yes o No o Don't Know o American Indian/Native American Canavan disease o Yes o No o Don't Know o Ashkenazi Jewish Bloom syndrome o Yes o No o Don't Know o Asian - American Gaucher disease o Yes o No o Don't Know o Cajun/French Canadian Niemann-Pick disease o Yes o No o Don't Know o Caucasian Fanconi Anemia o Yes o No o Don't Know o Eastern European Familial Dysautonia o Yes o No o Don't Know o Hispanic/Caribbean Muscular Dystrophy o Yes o No o Don't Know o Northern European Neurologic (brain/spine) o Yes o No o Don't Know o Southern European Neural Tube Defects o Yes o No o Don't Know o Other (specify ) Bone/Skeletal Defects o Yes o No o Don't Know Dwarfism o Yes o No o Don't Know Would you like to be screened for: Developmental delay o Yes o No o Don't Know o Cystic Fribrosis: Y N Learning problems o Yes o No o Don't Know o Sickle Cell Anemia: Y N Polycystic kidney disease o Yes o No o Don't Know o Tay-Sachs Disease: Y N Heart defect from birth o Yes o No o Don't Know o Thalasemia: Y N Down syndrome o Yes o No o Don't Know Other chromosome defects o Yes o No o Don't Know Marfan syndrome o Yes o No o Don't Know Hemophilia o Yes o No o Don't Know Sickle Cell Anemia o Yes o No o Don't Know Thalassemia o Yes o No o Don't Know Galactosemia o Yes o No o Don't Know Deafness/Blindness o Yes o No o Don't Know Color Blindness o Yes o No o Don't Know Hemochromatosis o Yes o No o Don't Know o None of the above o Other (Specify) SPOUSE/MALE PARTNER'S SIGNATURE _ DATE I confirm that I have reviewed the information above. PHYSICIAN'S SIGNATURE_ DATE Physician Notes (for office use only) Page 8