FEMALE MEDICAL HISTORY AND INFORMATION
Reason for Visit: :
Infertility Evaluation
Sperm Insemination
Other
How many months
have you been trying to conceive (unprotected intercourse or inseminations)?
Pregnancy Summary
Total Number of ALL Pregnancies:
Number of Full Term Deliveries :
Of these, how many were live births?
How many were stillborn?
Number of Premature (less than 37 weeks) Deliveries:
Of these, how many were live births?
How many were stillborn?
Number of Miscarriages (less than 20 weeks):
Number of Ectopic/Tubal Pregnancies:
Number of Elective Terminations (Abortions):
Any Pregnancies with Birth Defects?
No
Yes - explain
Menstrual History
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?
days
Dates of the 1st day of your last 2 menstrual periods:
;
Age when you had your first period:
years old
Age when you first noticed:
Breast development:
years old
Pubic hair:
years old
Underarm hair:
years old
How many periods do you have per year?
Do you need medication to bring on a period?
Yes- What type?
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?
No
Yes:Always
Sometimes
Recently
In the past
Contraceptive History
None
Condoms - dates of use
Diaphragm - dates of use
IUD - dates of use
Birth control pills used date
- complications?
Never used birth control pills
Injectable contraception (Depo-Provera®, Lunelle™, etc.) - dates of use
- complications?
Skin patch - dates of use
- complications?
Foam or Jelly
Tubal sterilization procedure (tubes tied) - date (month/year
Tubes untied - date (month/year)
Did your mother take DES when she was pregnant with you?
Yes
No
Don’t know
Sexual History Start
How many times do you have intercourse per week?
times per week
None
Not Applicable
Have you used over-the-counter ovulation kits to time intercourse?
Yes
No
Do you have pain with intercourse?
Yes
No
Do you use lubricants (K-Y Jelly®, etc.) during intercourse?
No
Yes - what types
Any bleeding after the intercourse yes
Yes
No
Any prior exposure to sexually transmitted diseases or pelvic infections?
Yes (check all that apply)
No
Chlamydia - date
Gonorrhea - date
Herpes - date
Genital warts/HPV - date
Syphilis - date
HIV/AIDS - date
Hepatitis - 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?
Yes (check all that apply)
No
Colposcopy
Cryosurgery (Freezing)
Laser treatment
Conization
LEEP procedure
Breast Screening History
Have you ever had a mammogram?
No
Yes- Date
Result:
Normal
Abnormal- explain
Do you perform self breast exams?
Yes
No
Medical History
Are you allergic to any medications?
No
Yes (Please list and describe reactions)
Are you allergic to any foods (peanuts, eggs, etc.)?
No
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(pls list)
Do you have any medical problem(s)?
No
Yes (Please list type, dates, and treatments.)
(1).
(4).
(2).
(5).
(3).
Surgical History
Did you have surgeries on your abdomen / reproductive organs ( uterus/ tubes/ ovaries)
No
Yes specify
Social History
(caffeine, cigarettes, alcohol, Drugs)
Physical Symptoms
General: Head, Eyes, Ears, Nose and Throat: Respiratory
Endocrine/Hormonal: Breasts: Neurological Problems:
Gastrointestinal: Genito-Urinary: Skin/Extremities:
Musculoskeletal: Hematologic: Cardiovascular:
Mental Health Problems:
Family History
PRIOR INFERTILITYTESTING AND TREATMENT
Have you had prior infertility testing or treatment elsewhere?
Prior Tests
(check all that apply):
Yes
No
Basal body temperature chart
(date/
/results
Thyroid test
(date/
/results
Ovulation test kit
(date/
/results
Day 3 blood test for FSH level
(date/
/results
Hysterosalpingogram (HSG)
(date/
/results
Laparoscopy surgery
(date/
/results
Hysteroscopy surgery
(date/
/results
Progesterone blood test
(date/
/results
Prolactin blood test
(date/
/results
Prior Treatment
(check all that apply):
# of cycles Dates (mo/year) (mo/year) Pregnant
Intrauterine insemination:
From
to
Yes
No
Clomiphene citrate with timed intercourse:
From
to
Yes
No
maximum # tablets per day
Clomiphene citrate with insemination:
From
to
Yes
No
maximum # tablets per day
Daily fertility drug injections with
insemination:
From
to
Yes
No
maximum # tablets per day
Completed in vitro fertilization cycle(s):
1.
# eggs
#embryos transferred
#frozen
Yes
No
2.
# eggs
#embryos transferred
#frozen
Yes
No
3.
# eggs
#embryos transferred
#frozen
Yes
No
4.
# eggs
#embryos transferred
#frozen
Yes
No
Frozen embryo transfers:
1.
#embryos transferred
Yes
No
2.
#embryos transferred
Yes
No
3.
#embryos transferred
Yes
No
4.
#embryos transferred
Yes
No
Canceled in vitro fertilization attempt(s):
Additional Information/Complications :
EMOTIONAL STATUS
Date:
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