To better focus your visit with the doctor based on your needs, please complete this form
Personal Information Name: ______________________________________ Today’s Date: __________
Social Security Number: _______-_____-_______ Date of Birth: ___/___/_____
Address: _________________________________________________________
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Phone numbers Cell _________--___________--___________
Home _________--___________--___________
Work _________--___________--___________
Email address: _____________________________________________________
Partner’s Name (if applicable): __________________ Date of Birth: ___/___/_____
Partner’s Social Security Number: _________-_______-_________
Who referred you to us?_______________________________________________
Your Obstetrician/ Gynecologist: ________________________________________
Your Internist/ Family Physician (if you have one): _____________________________
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What is the reason for your visit today and how long have you been trying to conceive?
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Prior Fertility Testing and Treatment Have you been tested for infertility before? Yes No
If yes, with whom, where and when? ______________________________________________
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What cause(s) of infertility was diagnosed? Check all that apply:
Other, please list: ___________________________________________________________
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Have you had any of the following tests? Check all that apply:
Hormonal Testing (Prolactin, Progesterone)
Genetic testing (e.g., Cystic fibrosis)
Other, please specify: ________________________________________________________
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Have you ever taken medications to enhance your fertility? Yes No
Other, please list: ___________________________________________________________
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Have you ever undergone Intrauterine Insemination (IUI)? Yes No
Copyright 2014, Women’s Fertility Center. All rights reserved.
Have you ever taken Clomid or gonadotropins (Gonal F, Follistim) to induce ovulation? Yes No
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Have you undergone In Vitro Fertilization (IVF)? Yes No
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Medical History Do you have any medical problems? Yes No If yes, which one(s)? Check all that apply:
Gynecologic History At what age did you have your first period? ____________________________________________
Copyright 2014, Women’s Fertility Center. All rights reserved.
When was the beginning of your last (most recent) period? ________________________________
If yes, 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? (number of days of bleeding) _______________________
Do you have painful periods? never sometimes often usually
How would you describe the level of your pain? mild moderate severe
Do you have to take pain medication for your periods? Yes No
If yes, specify medication: ___________________________________________________
Do you bleed or spot between your periods? Yes No
When was your most recent Pap smear? _________ Was it normal? Yes No I don’t know
Have you ever had an abnormal Pap test? Yes No
If yes, when and what was done? _____________________________________________
When was your most recent mammogram? __________ Was it normal? Yes No I don’t know
Have you ever had an abnormal mammogram? Yes No
If yes, when and what was done? _____________________________________________
What form of contraception do you use or have you used in the past? _________________________
Have you ever taken birth control pills? Yes No
Have you ever used an intrauterine device (IUD)? Yes No
How many times per week do you and your partner have sexual intercourse? ___________________ How many times do you have intercourse around ovulation? ______________________________
Have you ever used used a basal body temperature chart? Yes No
If yes, what day of the cycle did your temperature rise? _____________________________
Have you ever used used an ovulation predictor kit (OPK)? Yes No
If yes, what day of the cycle did your kit turn positive? ______________________________
Do you ever have pain during intercourse? Yes No
Obstetrical History How many times have you been pregnant? ____________ How many of your pregnancies were full term births (>37 weeks)? ____________
1st pregnancy: What year? ____________ How long did it take to conceive? ___________________
Was infertility therapy required? Yes No If yes, what? _______________________________
Was the baby born alive? Yes No If yes, is the current partner the genetic father? Yes No
If not, the pregnancy Ended in miscarriage
Copyright 2014, Women’s Fertility Center. All rights reserved.
2nd pregnancy: What year? ___________ How long did it take to conceive? __________________
Was infertility therapy required? Yes No If yes, what? _______________________________
Was the baby born alive? Yes No If yes, is the current partner the genetic father? Yes No
If not, the pregnancy Ended in miscarriage
3rd pregnancy: What year? ____________ How long did it take to conceive? ___________________
Was infertility therapy required? Yes No If yes, what? _______________________________
Was the baby born alive? Yes No If yes, is the current partner the genetic father? Yes No
If not, the pregnancy Ended in miscarriage
4th pregnancy: What year? ____________ How long did it take to conceive? __________________
Was infertility therapy required? Yes No If yes, what? _______________________________
Was the baby born alive? Yes No If yes, is the current partner the genetic father? Yes No
If not, the pregnancy Ended in miscarriage
Additional pregnancies: What year? __________ How long did it take to conceive? ____________
Was infertility therapy required? Yes No If yes, what? _______________________________
Was the baby born alive? Yes No If yes, is the current partner the genetic father? Yes No
If not, the pregnancy Ended in miscarriage
Did you have any complications during or after your pregnancies? Yes No
If yes, explain: ____________________________________________________________
Surgical History Have you ever had surgery? Yes No
If yes, which one(s)? Check all that apply:
Other, please list: ____________________________________________________________
Do you take any prescription or over-the-counter medications regularly? Yes No
If yes, please list: _______________________________________________________
If yes, please list: ______________________________________________________
What is your current weight? (in lbs.) ________What is your height? (in inches)____
Have you lost or gained more than 10 pounds of weight in the last year? Yes No
Have you ever had an eating disorder? (anorexia, bulimia) Yes No
If yes, explain: ________________________________________________________
Copyright 2014, Women’s Fertility Center. All rights reserved.
Social History What is your ethnicity? African American
Other: _______________________________________
What do you do professionally? _____________________________________________________
You are: Married Single Divorced Widowed
Do you follow a particular food diet or have any special dietary habits? Yes No
If yes, what is it? ______________________________________________________
If yes, what type of exercise do you do and for how many hours per week?
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Do you currently use or have you recently used (check all that apply):
Caffeine. How many cups of coffee/ caffeinated tea/ cola do you usually drink daily?____________
Alcohol. How many glasses of alcohol do you usually drink per week? ______________________
Tobacco. How many cigarettes do you usually smoke per day? ____________________________
Recreational Drugs. (Marijuana, Cocaine, etc.) Which one(s) and how often?__________________
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Family History Are there any children in the family with birth defects or mental retardation? Yes No Did your mother have any difficulty with conceiving or with recurrent pregnancy loss? Yes No
If yes, who: ____________________________________________________________
Does anyone in your family have (please check all that apply & list whom):
Infertility ____________________________________________________________
Recurrent abortions (2 or more miscarriages) _________________________________
Blood clots in the leg (DVT) or lung (PE) _____________________________________
Type II diabetes _____________________________________________________
Breast cancer _______________________________________________________
Ovarian cancer ______________________________________________________
Colon cancer ________________________________________________________
Did your mother take diethyistibestrol (DES) when she was pregnant with you? Yes No
At what age did your mother go through menopause? ____________________________________
Copyright 2014, Women’s Fertility Center. All rights reserved.
Editorial Board Vol 14, no 7–July 2007 (issue no Executive Editor: Mr WONG Man-kong ACA Secretariat ___________________________________________________________________________________________________ 59th ACA Meeting The 59th ACA meeting will be held on 6 July 2007 (Friday) at 2:30 pm at the DH Conference Room, 21/F Wu Chung House, Wan Chai. There will be three main item
7th European Conference on Applications of Polar Dielectrics (ECAPD7) September 6-9, 2004, Liberec, Czech Republic List of invited speakers (25.5.2004) A. Bell (UK): “Temperature dependence and Non-Linearity of dielectrics with composition gradients“ R. Blinc (Slovenia): "Polar nanoclusters in relaxors" L. Bohatý (Germany): “Electromechanical and electro-optical prop