2347 Kennedy Rd. Suite 304 Scarborough, ONT M1T 3T8 Tel: (416)754-1010 Fax: (416)321-1239 Date: FEMALE MEDICAL & REPRODUCTIVE HISTORY (There are 5 pages - please ensure you answer all questions) General Information: NAME: Your Age: Duration of Relationship: PARTNER S NAME: His Age: Your Ethnic Origin: Any unsuccessful pregnancies or children from this relationship? Yes No Any pregnancies/children from a previous relationship? Yes No How long have you been trying to get pregnant? In the past six (6) months have you had 1. Body piercings Yes No 2. Tattoos Yes No If yes, please name the (company) Do you use or have you ever used (check all that apply): Alcohol: How many glasses per week do you usually drink? Wine: Beer: Liquor: Cigarettes: Do you currently smoke? Yes/No If yes, number per day? Ever been a smoker? Yes/No If yes, how long ago did you quit? Illicit or Recreational Drugs (marijuana, cocaine, etc) (If you would feel more comfortable not writing anything down, please discuss this directly with your physician)
- 2 - Employment Background: Nature of present/past employment (brief description, number of years) Are you now or have you ever been exposed to any of the following during employment: Heat Toxic Fumes Chemicals Nuclear Radiation Other: Do you travel frequently as part of your employment? If yes, specific frequency per Month Year Medical History: Height: ft. ins Current Weight: lbs. Have you lost or gained more than 20 lbs. over the past 12 months? Yes No If yes, gained/lost lbs. Do you follow any particular food diet or have any specific dietary habits? Yes No If yes, explain: Are you currently taking any dietary supplements? Yes No If yes, please identify: ALLERGIES? Please list: Date of Last Pap Smear: Menstruation: Result: Periods started at age? Are your periods regular or irregular? Are you taking any medications to regulate your periods? Yes/No If yes, name med: How many days between the start of each period? Average number of days of flow? First day of your last period
- 3 - Obstetrical History: How many times have you been pregnant? How many full term or premature deliveries? Ages of your children: # of Miscarriages: Stillbirths: Therapeutic Abortions: Ectopics: CIRCLE ANY OF THESE YOU HAVE HAD: Arthritis Epilepsy (convulsions) Phlebitis Diabetes Tuberculosis Anaemia Heart Disease Venereal Disease Rheumatic Fever Bladder Infections Hepatitis Migraine Headaches Jaundice High Blood Pressure Asthma Crohn s Disease Uterine Fibroids Thyroid Disease Severe depression Cancer* Kidney Disease * Please identify date of diagnosis, type of cancer, treatments & medications: LIST ANY OPERATIONS & DATES: LIST ANY MEDICATIONS YOU ARE PRESENTLY TAKING: Are you currently taking folic acid? Yes No (all women trying to achieve pregnancy should be taking 5 mg/day)
- 4 - FAMILY HISTORY: Are you parents alive and well? Yes No How many brothers/sisters do you have? Are there any diseases that run in your family (parents/siblings/aunts/uncles)? Yes No If yes, please identify: Circle any of the below occurring in your family: Birth Defects Twins, Triplets Kidney Disease Heart Disease High Blood Pressure Stroke Diabetes Cancer Tuberculosis INFERTILITY HISTORY: What is the reason you ve been told is the cause of your infertility? What is the status of your fallopian tubes (ie: open/blocked/absent)? Please note: It is important if you have ever undergone inseminations or IVF treatments in the past, that you obtain copies of those treatment records for our physician s review. Have you ever undergone any artificial inseminations? Yes No If yes, - Number of inseminations: Over what period of time: When was your last insemination: Was your partner s sperm used in all attempts? Yes No Was donor sperm ever used? Yes No If yes, how many times?
- 5 - Have your ever had an IVF treatment trial before? Yes No If yes: How many IVF trials were performed? Was your partner s sperm used? Yes No Was the ICSI (sperm injection)procedure used? Yes No List the drugs used in your treatment: Please fill in the below information regarding your treatment(s): Name of Treatment # of eggs # of embryos #embryos Pregnancy Date Clinic Cancelled? Retrieved Produced Transferred Yes/No Were there any concerns expressed about: $ poor response to the fertility drugs Yes No $ poor quality of eggs Yes No $ poor fertilization of the eggs Yes No $ poor quality sperm Yes No $ poor quality embryos Yes No Were any embryos frozen as a result of any of your IVF treatments? Yes No If yes, how many frozen embryo transfers have you undergone? Did any pregnancies result from the frozen transfers? Yes No Please document any additional information that you feel is important for us to know: