FEMALE PATIENT HISTORY
I. IDENTIFYING INFORMATION Date:______Name: ______Partners Name: ______Date of Birth: ______Partners Date of Birth: ______Duration of Relationship: ______Duration of Infertility: ______Nature of present employment (title, brief description) ______
II. MEDICAL HISTORY YES NO Weight: ______Height:______Blood Type (if known) ______Have you lost greater than 20 pounds of weight in the last year? ...... Do you follow a particular food diet or have any special dietary habits? ...... If yes, specify: ______List the forms and frequency of regular vigorous exercise (swimming, cycling, running) and age you began: Exercise: ______Hrs/Week: ______Age: _____ Exercise: ______Hrs/Week: ______Age: _____ Have you ever had pelvic surgery? ...... If yes, specify date and type: ______Do you have or have you ever had (check all that apply): Anemia Epilepsy Ovarian Cysts Appendicitis Gallbladder Problems Parasitic Infection Arthritis Gonorrhea Pelvic Infection Blood Transfusions Heart Disease Pneumonia Breast Milky Discharge Hepatitis Poor Sense of Smell Breast Soreness Herpes Rheumatic Fever Breast Tenderness Hirsutism (Excessive Hair Scarlet Fever Cancer: Growth) Seizures Specify______ High Blood Pressure Syphilis ______ Immunization: Thyroid Problems Chlamydia - German Measles Tuberculosis Chronic Bronchitis Kidney Infection Ulcers Chronic Headaches Liver Problems Vaginitis (Trichomoniasis, yeast) Colitis Loss of Balance # of episodes______ Color Blind Measles: German Visual Disturbances Diabetes Measles: Regular Any Allergies: List______ Dizziness Neurological Problems ______ Endometriosis Nongonococcal Urethritis ______
Have you ever been treated for cancer? ...... If yes, explain therapy: ______Have you ever received X-rays to the pelvic area for therapy or diagnosis? ...... If yes, specify: ______Within the last year, have you taken any prescription medications? ...... If yes, list all 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 use or have you ever used (check all that apply): Alcohol – How many glasses per week do you usually drink? Wine ______Beer ______Cocktails______ Cigarettes – Number of packs per day______ Illicit or Recreational Drugs (Marijuana, Cocaine, etc.) If you would feel more comfortable not writing anything down, please discuss this directly with your physician. Specify: ______
III. MENSTRUAL AND PREGNANCY HISTORY YES NO
Age at first period? ______When was your last period? ______Are your periods regular? ...... 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?______Use: Tampons? Pads? 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? ...... How many pregnancies (including abortions) have you had? ______
Infertility therapy Baby Is current When? End in End in Ectopic Pregnancy required to born partner (Year) Abortion? Miscarriage? Pregnancy? conceive? alive? the father? 1st 2nd 3rd 4th 5th
Were there any complications during or after you pregnancies? ...... If yes, explain ______Did your mother have any difficulty with conception or pregnancy? ...... If yes, explain ______How long have you been trying to get pregnant? ______Did your mother take diethylstilbestrol (DES) when she was pregnant with you? ......
IV. CONTRACEPTIVE/SEXUAL HISTORY YES NO What form of contraception do you use now or have you used in the past? Check all that apply: 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 ______
If you have 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 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 YES NO
Is there a family history of infertility? ...... If yes, who (list all members and relationship to you): ______Is there a history of hormonal disorders in your family? ...... If yes, who and what type: ______
VI. HISTORY OF FERTILITY THERAPY YES NO
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®) hCG (Profasi®, A.P.L. ®) hMG (Pergonal®) bromocriptine (Parlodel®) estrogens danazol (Danocrine®) progesterone urofollitropin or FSH (Metrodin®) prednisone (or cortisone‐like drugs) Other – Specify ______ antibiotics ______ GnRH or LHRH (Factrel®) None
Which of the following tests have you had performed? Check all that apply and the results if known: BBT When? ______Results______ Postcoital Test When? ______Results______ Hormonal Assays (FSH, LH, prolactin, estrogen When? ______Results______DHEA‐S, testosterone, progesterone)