Patient History Form Please complete this form prior to your visit. This form was developed by the American Society for Reproductive Medicine and CARE to assist physicians and patients in obtaining a complete infertility history. It consists of three parts: Part I: Contact information; Part II: Female medical history; Part III: Male medical history (if applicable) Part I: Patient Registration Form Patient Information: Legal Name: Date of Birth: Age: Address: SSN: Email: Please indicate which number to call or leave a message. Referred by: Phone (H): Insurance OB/Gyn Primary Care MD Friend Other Phone (C): Fax: Insurance Carrier: Occupation: Subscriber #: Employer: Preferred Pharmacy: Work Address: Pharmacy Phone: Marital Status: Partner Information: Legal Name: Date of Birth: Age: Address: SSN: Email: Please indicate which number to call or leave a message. Referred by: Phone (H): Insurance OB/Gyn Primary Care MD Friend Other Phone (C): Fax: Insurance Carrier: Occupation: Subscriber #: Employer: Preferred Pharmacy: Work Address: Pharmacy Phone: Marital Status: Emergency Contact: Name: Relationship: Phone: Physicians: OB/Gyn Other: Name: Name: Address: Address: Phone: Phone: Medical Doctors are licensed and regulated by the Medical Board of California (www.mbc.ca.gov; 800.633.2322) Dr. Karen J. Purcell is Board Certified by the American Board of Obstetrics and Gynecology in Reproductive Endocrinology and Infertility. Patient Signature: Date: 1
Part II: Patient Medical History Form Main Reason for Visit: Fertility Evaluation Fertility Treatment Sperm Insemination Other What are your expectations for this visit? What questions do want answered at this visit? Medical History Height: (ft/in) Weight: (lbs) Are you allergic to any medications? No Yes (Please list and describe reactions) Are you allergic to any foods (peanuts, eggs, etc.)? No Yes (If 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 supplements? No Yes (Please list) Do you have or have you had any medical problem(s)? (If yes, please list type, dates, and treatments.) Anemia Blood clots Bleeding disorder Blood transfusion Cancer Diabetes Hypertension Heart Disease Rheumatic fever Scarlet fever Mitral valve prolapse Heart murmur Gall bladder disorder Hepatitis or liver disease Psychiatric disorder Seizures Stroke Thyroid disorder Kidney disorder Other Vaccinations: Have you had the following vaccinations? Chickenpox (Varicella) Yes (dates ) No Don t Know MMR Measles, Mumps, and Rubella Yes (dates ) No Don t Know BCG (Tuberculosis): Yes (dates ) No Don t Know Hepatitis B Yes (dates ) No Don t Know Polio Yes (dates ) No Don t Know Hepatitis A Yes (dates ) No Don t Know Tetanus Yes (dates ) No Don t Know Influenza Yes (dates ) No Don t Know 2
Surgical History Have you had any operations or hospitalizations? No Yes (List all in chronologic order.) Year Reason and Type of Surgery (1) (2) (3) (4) Did you have any anesthesia problems? No Yes (describe ) Menstrual History Date of your last period: / / Date of your period before that: / / Age when you had your first period: years old Age when you first noticed: Breast development: Pubic hair: Underarm hair: Menstrual cycle pattern (check all that apply): Regular periods Irregular periods Spotting before periods No periods Heavy periods Light periods 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? How many periods do you have per year? Do you need medication to bring on a period? No Yes - what type? If you do not have periods, at what age did you stop having them? years old Do you have severe cramping/ pain with your periods? No Yes: Always Sometimes Recently In the past Did you mother take DES when she was pregnant with you? No Yes Don t know Contraceptive History None Condoms - dates of use Foam or Jelly Diaphragm - dates of use IUD - dates of use Birth control pills - dates of use - complications? Skin patch - dates of use - complications? Injectable contraception (Depo-Provera, Lunelle, etc.) - dates of use - complications? Tubal sterilization (tubes tied) - date (month/year) / - Tubes untied - date (month/year) / Sexual History Are you sexually active No Yes Is your partner Male or Female How many times do you have intercourse per week? None Not applicable Have you used over-the-counter ovulation kits to time intercourse? No Yes Do you have pain with intercourse? No Yes Do you use lubricants (K-Y Jelly, etc.) during intercourse? No Yes - what types? Have you had any of the following sexually transmitted diseases or pelvic infections? No Yes (check all that apply) Chlamydia - date Gonorrhea - date Herpes - date Genital warts/hpv date Syphilis - date HIV/AIDS - date Hepatitis - date Other - date Pap Smear History When was your last pap smear (month and year)? / Normal Abnormal When was your last abnormal pap smear? / Not applicable Have you undergone any procedures as a result of an abnormal pap smear? No Yes Check all that apply: Colposcopy Cryosurgery (Freezing) Laser treatment Conization LEEP Breast Screening History Do you perform breast self-exams? No Yes Have you ever had a mammogram? No Yes - date / ; Result: normal abnormal - explain 3
Pregnancy Summary: Total pregnancies Livebirths: Stillbirths: Miscarriages Ectopics Abortions Total # of Deliveries # Full-term # Preterm Deliveries (<37 weeks) Adopted children Have you had any pregnancies with Birth Defects? No Yes explain Date Pregnancy Ended or Delivered 1. 2. 3. 4. Miscarriage, Ectopic, or Abortion? Months to Conception Treatments to Conceive? Delivery Type (D&C, C-Section) Complications? Sex (Male Or Female) Current Partner? (Yes or No) Fertility History Do you have any personal, ethical, or religious objections to any tests or treatments such as insemination, in vitro fertilization, egg donation, sperm donation, or masturbation to collect a semen sample, etc.? No Yes Please state: How long have you had regular unprotected intercourse? months How long have you been actively trying to conceive? months Have you had prior infertility testing or treatment elsewhere? No Yes Prior Tests (check all that apply): Basal body temperature chart (date / results ) Thyroid test (date /results ) Day 3 blood test for FSH level (date / results ) Laparoscopy surgery (date / results ) Progesterone blood test (date / results ) Ovulation test kit (date / results ) Hysterosalpingogram (HSG) (date / results ) Hysteroscopy surgery (date / results ) Prolactin blood test (date / results ) Prior Treatment (check all that apply): Treatment Type Intrauterine Insemination alone Clomid with timed intercourse: # tablets per day? Clomiphene with insemination: # tablets per day? Clomiphene with insemination: # tablets per day? Letrozole (Femara) with insemination: # tablets per day? Daily fertility drug injections with insemination: # vials per day? Canceled in vitro fertilization attempt(s): Completed in vitro fertilization cycle(s): 1. # eggs # transferred #frozen 2. # eggs # transferred #frozen Frozen embryo transfers: 1. # transferred 2. # transferred Acupuncture Other (describe) # of Cycles Dates Not Pregnant Delivered Miscarriage Ectopic Additional Information/Complications: 4
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? No 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. Social History Do you exercise? If yes, what type and how often? How many caffeinated beverages (coffee, tea, soda) do you drink per week? None Do you smoke cigarettes? No Yes How many/day? How many years? Quit - when? Do you drink alcohol? No Yes Beer - # per week Wine- # per week Liquor - # per week Do you use marijuana, cocaine, or any other recreational drug? No Yes (describe ) Are you aware of any radiation exposures other than X-rays? No Yes (describe ) Physical Symptoms General: Head, Eyes, Ears, Nose, and Throat: Respiratory: Recent weight gain or loss Dizziness Loss of sense of smell Shortness of breath Anorexia/Bulimia Headaches Chronic nasal congestion Asthma Bronchitis Lack of energy Blurred vision Ringing ears Pneumonia Tuberculosis Fever/Chills Hearing loss/deafness Bloody cough Other Other Other Endocrine/Hormonal: Breasts: Neurological Problems: Diabetes Hair loss Discharge (clear? bloody? milky? ) Weakness/Loss of balance Thyroid gland problems Lumps Pain Cancer Seizures/Epilepsy Rapid weight gain or loss Abnormal mammogram Headaches Excessive hunger/thirst Reduction Migraine headaches Temperature intolerance Augmentation/ Implants Numbness hot flashes or feeling cold (saline? silicone? ) Memory loss Other Other Other Gastrointestinal: Genito-Urinary: Skin/Extremities: Nausea/Vomiting Ulcers Bladder infections Unexplained rash Hepatitis Diarrhea Kidney infections Acne Blood in your stools Constipation Vaginal infections Leaking urine Skin cancer Inflammation Irritable Bowel Syndrome Frequent urination Burn injury Change in bowel habits Blood in the urine Moles changing in appearance Colitis (Ulcerative or Crohn s) Herpes Excess hair growth Other Other Other Musculoskeletal: Hematologic: Cardiovascular: Unusual muscle weakness Blood clotting disorder/blood clot Palpitations/Skipped beats Decreased energy/stamina Sickle cell Anemia Thrombophlebitis Chest pain Heart attack Rheumatoid arthritis Easy bruising Stroke Murmurs Lupus Erythematosus Swollen glands/lymph nodes High blood pressure Myasthenia gravis Other Blood transfusions (dates/reasons ) Other Rheumatic fever Mitral valve Other 5
Family History What is your ancestry? Check all that apply African-American Asian-Chinese Hispanic Mexican Native American Asian-Japanese Hispanic Spain Ashkenazi Jewish Asian-Korean Hispanic Central American Caucasian-Northern European Asian-Indian Hispanic South America Caucasian-Russian Asian-Filipino Middle Eastern Caucasian-Southern European Asian-Vietnamese African Asian-Other: Other (specify ) Country of Origin: Living Cause of Death/Age at Death Mother Yes - age No Father Yes - age No Brother(s) Yes - age No Yes - age No Sister(s) Yes - age No Yes - age No Maternal Grandmother Yes - age No Maternal Grandfather Yes - age No Paternal Grandmother Yes - age No Paternal Grandfather Yes - age No Disorders in Your Family List Relationship to You Birth Defects Don t Know No Yes Blood syndrome Don t Know No Yes Bone/Skeletal Defects Don t Know No Yes Canavan Disease Don t Know No Yes Breast Cancer Don t Know No Yes Ovarian Cancer Don t Know No Yes Colon Cancer Don t Know No Yes Other Cancer Don t Know No Yes Color Blindness Don t Know No Yes Cystic Fibrosis Don t Know No Yes Deafness/Blindness Don t Know No Yes Developmental delay Don t Know No Yes Diabetes Don t Know No Yes Down Syndrome Don t Know No Yes Dwarfism Don t Know No Yes Endometriosis Don t Know No Yes Familial Dysautonia Don t Know No Yes Faconi Anemia Don t Know No Yes Galactosemia Don t Know No Yes Gaucher disease Don t Know No Yes Heart defect from birth Don t Know No Yes Heart Problems Don t Know No Yes Hemochromatosis Don t Know No Yes Hemophilia Don t Know No Yes Infertility Don t Know No Yes Learning Problems Don t Know No Yes Marfan Syndrome Don t Know No Yes Menopause before age 40 Don t Know No Yes Muscular Dystrophy Don t Know No Yes 6
Neural Tube Defects Don t Know No Yes Neurologic (brain/spine) Don t Know No Yes Neimann-Pick Disease Don t Know No Yes Obesity Don t Know No Yes Polycystic Kidney Disease Don t Know No Yes Psychiatric problems Don t Know No Yes Sickle Cell Anemia Don t Know No Yes Tay-Sachs Disease Don t Know No Yes Thalassemia Don t Know No Yes Thyroid problems Don t Know No Yes Tuberculosis Don t Know No Yes High blood pressure Don t Know No Yes Glaucoma Don t Know No Yes High Cholesterol Don t Know No Yes Gallstone Don t Know No Yes Hepatitis Don t Know No Yes Other- Specify PATIENT S SIGNATURE DATE 7
Part III: Male Medical History and Information Complete with your male partner if applicable. Have you been evaluated by a Urologist? No Yes Have you previously conceived with another woman? Yes: How many times? No: Birth control used? Have you had a semen analysis? No Yes If yes, what were the results? Date: / Volume: Count: Motility: Morphology: Do you have difficulty with erections? No Yes Are you able to ejaculate inside your partner s vagina? No Yes Do you have retrograde ejaculation of sperm into the bladder? No Yes Have you had any of the following sexually transmitted diseases or pelvic infections? No Yes (check all that apply) Chlamydia - date Gonorrhea - date Herpes - date Genital warts/hpv - date Syphilis - date HIV/AIDS - date Hepatitis - date Other Have you had a history of undescended testicles? No Yes - One side Both Do you have scrotal or testicular pain? No Yes Did you have the mumps after puberty? No Yes Have you had prior injury to your testicles requiring hospitalization? No Yes Have you been diagnosed with any of the following diseases? Diabetes Mellitus: No Yes Cancer: No Yes Multiple Sclerosis: No Yes Neurologic problems: No Yes Prostatic infections: No Yes Urinary infections: No Yes High Blood Pressure: No Yes, any medications? Have you had any fever in the last 3 months? No Yes Have you had a vasectomy? No Yes (date ). Have you had a vasectomy reversal? No Yes (date ) Have you had surgery for varicoceole repair? No Yes Did you undergo any bladder or penis surgery as a child? No Yes Have you had hernia surgery? No Yes Are you exposed to prolonged heat in the workplace? No Yes Have you had chemotherapy for cancer? No Yes Are you allergic to any medications? No Yes (Please list and describe reactions) Any other allergies (i.e. food, seasonal)? List your current medications: List any current medical problem(s): How many caffeinated beverages do you drink per week? None Do you smoke cigarettes? No Yes How many/week? How many years? Quit - when? Second-hand Exposure No Yes Do you drink alcohol? No Yes Beer - # per week Wine- # per week Liquor - # per week Do you use marijuana, cocaine, or any other similar drug? No Yes (describe ) Do you use herbal medicines/vitamins or health food store supplements? No Yes (describe ) Are you aware of any radiation/toxic materials exposure? No Yes Do you use hot tubs regularly? No Yes Did your mother take DES during pregnancy to prevent miscarriage? No Yes Don t know Have any of your immediate family members had difficulty conceiving a child? No Yes If yes, please describe 8
Family History What is your ancestry? Check all that apply African-American Asian-Chinese Hispanic Mexican Native American Asian-Japanese Hispanic Spain Ashkenazi Jewish Asian-Korean Hispanic Central American Caucasian-Northern European Asian-Indian Hispanic South America Caucasian-Russian Asian-Filipino Middle Eastern Caucasian-Southern European Asian-Vietnamese African Asian-Other: Other (specify ) Country of Origin: Living Cause of Death/Age at Death Mother Yes - age No Father Yes - age No Brother(s) Yes - age No Yes - age No Sister(s) Yes - age No Yes - age No Maternal Grandmother Yes - age No Maternal Grandfather Yes - age No Paternal Grandmother Yes - age No Paternal Grandfather Yes - age No Disorders in Your Family List Relationship to You Birth Defects Don t Know No Yes Blood syndrome Don t Know No Yes Bone/Skeletal Defects Don t Know No Yes Canavan Disease Don t Know No Yes Breast Cancer Don t Know No Yes Ovarian Cancer Don t Know No Yes Colon Cancer Don t Know No Yes Other Cancer Don t Know No Yes Color Blindness Don t Know No Yes Cystic Fibrosis Don t Know No Yes Deafness/Blindness Don t Know No Yes Developmental delay Don t Know No Yes Diabetes Don t Know No Yes Down Syndrome Don t Know No Yes Dwarfism Don t Know No Yes Endometriosis Don t Know No Yes Familial Dysautonia Don t Know No Yes Faconi Anemia Don t Know No Yes Galactosemia Don t Know No Yes Gaucher disease Don t Know No Yes Heart defect from birth Don t Know No Yes Heart Problems Don t Know No Yes Hemochromatosis Don t Know No Yes Hemophilia Don t Know No Yes Infertility Don t Know No Yes Learning Problems Don t Know No Yes Marfan Syndrome Don t Know No Yes Menopause before age 40 Don t Know No Yes 9
Disorders in your Family (continued) Muscular Dystrophy Don t Know No Yes Neural Tube Defects Don t Know No Yes Neurologic (brain/spine) Don t Know No Yes Neimann-Pick Disease Don t Know No Yes Obesity Don t Know No Yes Polycystic Kidney Disease Don t Know No Yes Psychiatric problems Don t Know No Yes Sickle Cell Anemia Don t Know No Yes Tay-Sachs Disease Don t Know No Yes Thalassemia Don t Know No Yes Thyroid problems Don t Know No Yes High blood pressure Don t Know No Yes Glaucoma Don t Know No Yes High Cholesterol Don t Know No Yes Gallstone Don t Know No Yes Hepatitis Don t Know No Yes Other- Specify PATIENT S SIGNATURE DATE 10