Microsoft word - evaluation_newpatientfemale.docx

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: _________________________________________________________ _________________________________________________________ _________________________________________________________ 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): _____________________________ Copyright 2014, Women’s Fertility Center. All rights reserved. What is the reason for your visit today and how long have you been trying to conceive? _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Prior Fertility Testing and Treatment Have you been tested for infertility before? Yes No If yes, with whom, where and when? ______________________________________________ ________________________________________________________________________ What cause(s) of infertility was diagnosed? Check all that apply: Other, please list: ___________________________________________________________ ________________________________________________________________________ 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: ________________________________________________________ ________________________________________________________________________ Have you ever taken medications to enhance your fertility? Yes No Other, please list: ___________________________________________________________ ________________________________________________________________________ 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 ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Have you undergone In Vitro Fertilization (IVF)? Yes No ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 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? _______________________________________________________________________ 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?__________________ ____________________________________________________________________________ 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.

Source: http://www.womensfertilitycenter.com/wfc-wp/wp-content/uploads/2013/12/Evaluation_NewPatientFemale.pdf