New York Reproductive Wellness Female Medical History & Information
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- Alannah May
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1 New York Reproductive Wellness Female Medical History & Information Please complete this form prior to your meeting with the doctor. Leave blank anything that does not apply to you, that you have questions about or that you wish to speak with the doctor about in private. PROBLEM Reason for visit (e.g. infertility testing/evaluation, IVF, other)? How long have you had this problem? Please discuss the nature and severity of the problem: Do you have any personal, ethical, or religious objections to testing or treatments such as inseminations, IVF, egg donor IVF, masturbation to collect a semen sample? Y N If yes, please explain: PROBLEMS CONCEIVING or KEEPING A PREGNANCY? How long have you been having unprotected intercourse (in years/months)? Have any of these tests been done? (please provide medical records, if available; otherwise, testing date and results to the best of your memory)! Hysterosalpingogram or Sonohysterogram/water sonogram:!! Semen analysis:! Hormone testing (e.g. cycle day 3 FSH/estradiol, AMH, progesterone,! thyroid, prolactin levels):!! Laparoscopy:! Hysteroscopy:! PCOS Work-Up:! Pregnancy Loss Work-Up:! Premature Ovarian Failure Work-Up:! Ovulation test kits (do they indicate LH surges, and if so, what cycle day do! LH surges occur?):
2 PREVIOUS FERTILITY TREATMENTS Please specify # of cycles, the date(s) of treatment, the dosages of medications, and the outcome(s) (i.e. pregnant or not, ectopic pregnancy, or miscarriage). intrauterine/artificial insemination: Clomiphene citrate (e.g. Clomid or Serophene) with timed intercourse: Clomiphene citrate with insemination: Injectible medications with insemination: IVF cycles (also specify #eggs, #embryos transferred, #embryos frozen): Frozen embryo transfers (also specify #embryos transferred): Other treatments, or complications experienced (e.g. OHSS, DVT, hospitalization): MEDICAL HISTORY Please list all medical problems. Examples: autoimmune disorders (e.g. rheumatoid arthritis, SLE, myasthenia gravis), infections (e.g. chicken pox), thyroid disorder, diabetes, asthma, high blood pressure, heart disease, stroke, liver disease/ infection, kidney disease, blood clots (e.g. in leg or lung), bleeding disorder, cancer, and psychiatric disorders (e.g. depression, schizophrenia, bipolar disorder).! Medical problem!! When diagnosed; doctor caring for you;!!!!! treatment received 1.!!!! 2.!!!! 3.!!!!
3 4.!!!! SURGICAL HISTORY Please list all previous operative procedures, including dental work (e.g. dentures and bridges), and if any complications (e.g. anesthesia problems, other): Date! Procedure!! Diagnosis! Doctor/Hospital! Complications OBSTETRICAL HISTORY (Chronologically, from most recent) 1. Date (month/day/year) of delivery or end of pregnancy: Check which applies: Full term delivery Preterm delivery (less than 37 weeks) Ectopic/tubal pregnancy. If so, left or right? L R!! Treatment (please circle): methotrexate/ tube removed/ tube opened Elective termination (abortion) Miscarriage less than 20 weeks. If so, was a D&C needed? Y N Pregnancy ended or delivery occurred at how many weeks? Any complications during pregnancy (e.g. stillbirth, high blood pressure, preeclampsia, diabetes, etc.) or after delivery (e.g. heavy vaginal bleeding, retained placenta, etc.)? Y N Specify:
4 Any fertility treatments required? Y N If yes, please specify: How long did it take to get pregnant? Conceived with current partner? Y N 2. Date (month/day/year) of delivery or end of pregnancy: Check which applies: Full term delivery Preterm delivery (less than 37 weeks) Ectopic/tubal pregnancy. If so, left or right? L R!! Treatment (please circle): methotrexate/ tube removed/ tube opened Elective termination (abortion) Miscarriage less than 20 weeks. If so, was a D&C needed? Y N Pregnancy ended or delivery occurred at how many weeks? Any complications during pregnancy (e.g. stillbirth, high blood pressure, preeclampsia, diabetes, etc.) or after delivery (e.g. heavy vaginal bleeding, retained placenta, etc.)? Y N Specify: Any fertility treatments required? Y N If yes, please specify: How long did it take to get pregnant? Conceived with current partner? Y N 3. Date (month/day/year) of delivery or end of pregnancy: Check which applies: Full term delivery Preterm delivery (less than 37 weeks) Ectopic/tubal pregnancy. If so, left or right? L R!! Treatment (please circle): methotrexate/ tube removed/ tube opened Elective termination (abortion) Miscarriage less than 20 weeks. If so, was a D&C needed? Y N
5 Pregnancy ended or delivery occurred at how many weeks? Any complications during pregnancy (e.g. stillbirth, high blood pressure, preeclampsia, diabetes, etc.) or after delivery (e.g. heavy vaginal bleeding, retained placenta, etc.)? Y N Specify: Any fertility treatments required? Y N If yes, please specify: How long did it take to get pregnant? Conceived with current partner? Y N 4. Date (month/day/year) of delivery or end of pregnancy: Check which applies: Full term delivery Preterm delivery (less than 37 weeks) Ectopic/tubal pregnancy. If so, left or right? L R!! Treatment (please circle): methotrexate/ tube removed/ tube opened Elective termination (abortion) Miscarriage less than 20 weeks. If so, was a D&C needed? Y N Pregnancy ended or delivery occurred at how many weeks? Any complications during pregnancy (e.g. stillbirth, high blood pressure, preeclampsia, diabetes, etc.) or after delivery (e.g. heavy vaginal bleeding, retained placenta, etc.)? Y N Specify: Any fertility treatments required? Y N If yes, please specify: How long did it take to get pregnant? Conceived with current partner? Y N 5. Date (month/day/year) of delivery or end of pregnancy: Check which applies: Full term delivery Preterm delivery (less than 37 weeks) Ectopic/tubal pregnancy. If so, left or right? L R
6 !! Treatment (please circle): methotrexate/ tube removed/ tube opened Elective termination (abortion) Miscarriage less than 20 weeks. If so, was a D&C needed? Y N Pregnancy ended or delivery occurred at how many weeks? Any complications during pregnancy (e.g. stillbirth, high blood pressure, preeclampsia, diabetes, etc.) or after delivery (e.g. heavy vaginal bleeding, retained placenta, etc.)? Y N Specify: Any fertility treatments required? Y N If yes, please specify: How long did it take to get pregnant? Conceived with current partner? Y N (Please provide additional pregnancy information on a separate piece of paper.) GYNECOLOGICAL HISTORY When was the first day of your last period? Age when you had your first period: The number of days between the start of one period to the start of the next period? How many days of bleeding do you have? Do you have painful periods, no periods, heavy or light periods, or bleeding or spotting between periods? Y N Please explain: Do you need medication (e.g. Provera) to bring on periods? Y N If yes, which medications? Age when you first noticed: breast development ; pubic hair ; underarm hair Do you have a history of any of the following? Please specify treatment (e.g. I.V. antibiotics, hospitalization, other). Y N! infection in the fallopian tubes and uterus (i.e. pelvic inflammatory disease)! Y N! Chlamydia or gonorrhea infection; or, other STD/ sexually transmitted! disease (e.g. syphilis, HIV) Y N! Any other infection (e.g. tuberculosis)?! Which form of birth control have been used [oral contraceptives/ birth control pills, foam or jelly, injectable contraception (e.g. Depo-Provera), diaphragm,
7 progestin IUD, contraceptive patch, vaginal ring, withdrawal or rhythm method]? Y N If so, which one(s), when and for how long? Have you had you fallopian tubes tied? Y N! If yes, when and which method (if known) and indicate whether you have had a tubal reversal? When was you last Pap smear? Have you ever had any abnormal Pap smears? Y N If yes, did you need colposcopy, LEEP or a cone biopsy? Any history of breast masses or nipple discharge? Y N If yes, what kind of evaluation or treatment did you receive? Last mammogram, breast ultrasound or breast examination: ALLERGIES Please list all the medications or substances that you have an allergy to (e.g. latex, antibiotics, foods, environmental agents), and the reaction experienced (e.g. rash, hives, throat closure, anaphylaxis) MEDICATIONS (including herbals, vitamins, health food store supplements) Medication! Dosage of Medication! How many tablets/ day! Doctor
8 4. SOCIAL HISTORY How many cups of coffee, tea or caffeinated soda do you drink? Do you or have you ever smoked cigarettes (or used any tobacco product)? Y N If yes, how many packs/day and for how many years? Do you drink alcoholic drinks? Y N!! If yes, what type (i.e. beer, wine, liquor), how many glasses per day? Do you, or have you ever used other drugs (e.g. marijuana, cocaine, or any other recreational drugs)? Y N Please specify: Do you exercise? Y N!! If yes, what kind and how often? Current occupation: Are you aware of any potentially hazardous environmental exposure at work or home? Y N! Please specify: What is your ethnic background (e.g. Ashkenazi Jewish, Cajun/French Canadian, Italian or other Mediterranean, African American)? FAMILY HISTORY Do you have a family history of: Y N! breast cancer? If yes, which family members? Y N! ovarian cancer? If yes, which family members? Do you have a family or extended family members (include mother, father, sisters, brothers, children, paternal grandparents/ uncles/ aunts, maternal grandparents/ uncles/ aunts) with any of the following? thyroid disorder, diabetes, asthma, high blood pressure, heart disease, stroke, liver disease/ infection, kidney disease, blood clots (e.g. in leg or lung), bleeding disorder, cancers (e.g. colon) and psychiatric disorders (e.g. depression, schizophrenia, bipolar disorder)?
9 ! Family member!!!! Medical conditions 1.! 2.! 3.! 4.! 5.! 6.! Do you have any family history of any of the following?: Y N! inherited conditions [e.g. Cystic Fibrosis, Muscular Dystrophy, Sickle Cell Anemia, Thalassemia, Huntingtonʼs disease, Ashkenazi Jewish diseases (e.g. Tay-Sachs, Gaucher disease, Canavan Disease, Bloom Syndrome, Niemann- Pick disease, Fanconi Anemia, Familial Dysautonomia), Fragile X Syndrome, Spinal Muscular Atrophy, Hemophilia, Hemochromatosis, Dwarfism, Polycystic kidney disease, Marfan Syndrome, Galactosemia, color blindness, deafness/ blindness) Y N! Down Syndrome, or other chromosomal defects Y N! autism Y N! mental retardation Y N developmental delay Y N! birth malformations Y N! endometriosis Y N infertility Y N! menopause before age 40 Please specify: SIGNS & SYMPTOMS Do you have any of the following? Please elaborate: Y N! acne Y N! anxiety, stress or depression Y N! bladder or kidney problems Y N! blood in urine or stool Y N! breast discharge, lumps or pain
10 Y N! breathing difficulty Y N chest pain Y N! cough Y N! constipation Y N! diarrhea Y N! easy bruising tendency Y N! excessive hair growth Y N! fainting tendency Y N! headaches Y N! increased frequency of urination Y N increased weakness Y N! irregular heart beat Y N! leg or arm swelling, pain or redness Y N! nausea or vomiting Y N! pain in abdomen, pelvis or elsewhere Y N recent weight gain or loss Y N! skin discoloration or lesions Y N vaginal discharge Y N vision, smelling or hearing difficulties I confirm that I have read this form and that the information provided by me is true to the best of my knowledge. Patient Signature:! Date:!
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