infertilityform.doc

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infertilityform.doc

  1. 1. Department of Obstetrics and Gynecology Division of Reproductive Endocrinology and Infertility I. IDENTIFYING INFORMATION Date ________________ Name _____________________________ Partner’s name________________________ Address Telephone Number - Day: ( )_______________Evening: ( ) Date of Birth____________ Partner's Date of Birth_____________ Duration of Infertility_______________ What is you occupation?_____________________________________________________ What is your partner’s occupation?____________________________________________ What is the reason for your visit?______________________________________________ _________________________________________________________________________ II MENSTRUAL HISTORY YES NO Age at first period?______When was your last period?_____________________________ Are your periods irregular?....................................................................................................¨ ¨ If regular, what is the usual number of days between periods?_______________________ If no, how many times per year do you menstruate?_______________________________ What is the usual duration of your period?___________ Do you have difficulty predicting when your periods are going to start? ............................¨ ¨ Are cramps present before, during, or after your period? __________________________ Are cramps: ¨ Mild ¨ Moderate ¨ Severe?____________________________________ Do you have to take pain medication for cramps? ...............................................................¨ ¨ If yes, specify medication: __________________________________________________ Do you bleed or spot between periods?_________________________________________¨ ¨ II. HISTORY OF FERTILITY THERAPY Have you been treated for infertility before?------------------------------------------------------ ¨ ¨ If yes, who was your physician? ______________________________________________ What cause of infertility was diagnosed?________________________________________ What drugs have you taken for infertility? Check all that apply: ¨ clomiphene citrate (Serophene, Clomid) ¨ bromocriptine (Parlodel) ¨ estrogens ¨ HCG (Profasi, Pregnyl) ¨ HMG (Pergonal, Gonal-F Fertinex, Humegon) ¨ danazol (Danocrine) ¨ progesterone ¨ None ¨ prednisone ¨ GnRH (Lupron, Factrel) ¨ antibiotic 1
  2. 2. Which of the following tests have you had performed? Check all that apply and the results if known: ¨ Post-coital Test When?_____Result___________________ ¨ Temperature Charts When?_____Result___________________ ¨ Hormonal Assays (TSH, prolactin, progesterone) When?_____Results___________________ ¨ Urinary ovulation predictor kits When?_____Results:__________________ ¨ Ultrasound When?_____Results:__________________ ¨ Endometrial Biopsy When?_____Results:__________________ ¨ Semen Analysis When?_____Results:__________________ ¨ Sperm Antibodies When?_____Results:__________________ ¨ Hysterosalpingogram When?_____ Results:__________________ ¨ Hysteroscopy When?_____Results:__________________ ¨ Other hormones (DHEA-S, testosterone, etc.) When?_____Results:__________________ ¨ Pelvic Surgery (laparotomy or laparoscopy) When?_____Results:__________________ _______________________________________________________________________________ _______________________________________________________________________________ YES NO Were you ever diagnosed with a pelvic infection or adhesions?...........................................¨ ¨ Have you ever had an abnormal PAP smear?........................................................................¨ ¨ If yes, specify dates:________________________________________________________ Have you ever had cervical conization, cautery or freezing?................................................¨ ¨ Have you ever had any other surgery (D&C, ovarian, appendectomy, thyroid)?.................¨ ¨ If yes, please specify when and what was done:___________________________________ _________________________________________________________________________ Have you ever undergone artificial insemination or in vitro fertilization.............................¨ ¨ Have you had any treatment cycles (pills, injections, inseminations, IVF?) Please specify type and how many of each______________________________________________________ _________________________________________________________________________ If yes, using partner or donor sperm?....................................................................................¨ ¨ Is your partner seeing a doctor for evaluation of infertility?.................................................¨ ¨ Has he ever fathered a child with another woman?...............................................................¨ ¨ If yes, when?______________________________________________________________ III MEDICAL HISTORY Weight Height Blood Type (if known) _________ Do you have or have you ever had (check all that apply): 2
  3. 3. ¨ Anemia ¨ Epilepsy ¨ parasitic infection ¨ Appendicitis ¨ Gallbladder Problems ¨ Pelvic Infection ¨ Arthritis ¨ Gonorrhea ¨ Pneumonia or lung problems ¨ Blood Transfusions ¨ Heart Disease ¨ Poor Sense of Smell ¨ Breast Milky Discharge ¨ Hepatitis ¨ Rheumatic Fever ¨ Breast Soreness ¨ Herpes ¨ Seizures ¨ Breast Tenderness ¨ Hirsutism(Excess Hair Growth) ¨ Syphilis ¨ Cancer? Specify ¨ High Blood Pressure ¨ Thyroid Problems ¨ Immunization:German Measles ¨ Tuberculosis ¨ Chlamydia ¨ Kidney Infection ¨ Ulcers ¨ Chronic Bronchitis ¨ Liver Problems ¨ Vaginitis ¨ Chronic Headaches ¨ Loss of Balance ¨ Visual Disturbances ¨ Colitis ¨ Measles: German ¨ Any Allergies: ¨ Color Blindness ¨ Measles: Regular List ¨ Diabetes ¨ Neurological Problems ¨ Dizziness ¨ Nongonococcal Urethritis ¨ Endometriosis ¨ Ovarian Cysts Have you ever had any medical (non-surgical) problems that have brought you to a hospital? _________________________________________________________________________ _________________________________________________________________________ Any other medical problems that you are concerned with or think we should know about? _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ YES NO Within the last year, have you taken any prescription medications......................................¨ ¨ If yes, list the prescriptions and problems for which you were taking them_____________ _________________________________________________________________________ Are you taking any over-the-counter medications on a regular basis? ................................................................................................................................................¨ ¨ If yes, list all medications and diagnoses:________________________________________ Do you, and/or your partner use or have you ever used (check all that apply); Alcohol - How many glasses per week do you usually drink? Wine__ Beer Cocktail__ Cigarettes - Number of packs per day_______ Illicit or Recreational Drugs (Marijuana, Cocaine, etc.) If you would feel more comfortable not writing anything down, you can confidentially discuss this directly me.___________ ____________________________________________________________________ How many pregnancies, if any, have you had (including abortions)? year vaginal or C-section? complications? miscarriage? D&C? current father? 1st pregnancy 2nd pregnancy 3rd pregnancy 4th pregnancy 5th pregnancy IV CONTRACEPTIVE/SEXUAL HISTORY What form of contraception do you use now or have you used in the past? Check all that apply: 3
  4. 4. ¨ Pills (name): ¨ IUD Name ¨ Diaphragm ¨ Withdrawal ¨Foams/Jellies ¨ Condom ¨ Rhythm ¨ None ¨ Other:___________________________________ For each contraceptive method used, specify length of use and reason for discontinuation: Method Length of Use Reason for Discontinuation _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ YES NO If you've ever been on oral contraceptives (pills), were your periods regular after stopping the pills? .................................................................................................................¨ ¨ How many times per week do you and your partner have sexual intercourse? ___________ How long have you now been trying to get pregnant?______________________________ How many times do you have intercourse around ovulation?________________________ Is intercourse painful or difficult for you? ...........................................................................¨ ¨ Do you use lubricants for intercourse?..................................................................................¨ ¨ If yes, which one?__________________________________________________________ Do you douche before or after intercourse............................................................................¨ ¨ V. FAMILY HISTORY Is there any history of breast cancer in your family?............................................................¨ ¨ If yes, in whom?___________________________________________________________ Any female cancer? (ovarian, uterine cervical etc.)________________________________¨ ¨ Any significant family illness that we should know about? _________________________ _________________________________________________________________________ _________________________________________________________________________ Do you have anything else to add that this form did not address?_____________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Thank you again for taking the time to fill out this form. This will allow us more time to discuss treatment plans and any issues or concerns that you may have. 4

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