Address:

Other Referral:

Pharmacy:   Telephone:  

PRESENT PROBLEM

Reason for your clinic visit: 

Infertility                                     Polycystic Ovarian Syndrome

Abnormal Hair Growth           Endometriosis 

Irregular Periods                      Recurrent Miscarriages                  

 Other, specify:

Years of Duration:

Physician:

Describe as thoroughly as possible the background of your present problem.  Include all symptoms, how long you have experienced them and indicate whether they have become worse, lessened or stayed the same in severity over time.

Physician Notes

GENERAL MEDICAL HISTORY

Do you have any allergies?   No    Yes     

Specify:

Childhood illnesses: chicken pox  measles mumps

Others: (Describe):

Your general health:      Excellent      Good      Fair      Poor

Do you drink alcohol? 

Daily      Weekly     Monthly     Never    

Have you ever been in a serious accident?  No      Yes

(Describe):

Have you ever had a blood transfusion?  No      Yes

Approximate date(s):

List all serious medical illnesses with date(s): If hospitalized, where?

List all surgical procedures you have had, the approximate date(s), duration of your hospitalization(s) and name of hospital(s):

Have you undergone a surgical sterilization procedure? No  Yes (Describe):

List current medications: State the name of medication, indication for its use, and how long you’ve taken it.  Include both prescription and over-the-counter medication.

       Medication    /   Starting    /  Through    /   Amount    /    Indications

1.

2.

3.

Do you smoke cigarettes?  No Yes    Number of packs per day:

If you smoked in the past and have quit, give the approximate dates of smoking:

Drug usage in past year:

Marijuana       Cocaine           Depressants    Stimulants    Other:

State the substances and extent of exposure:

Have you had any difficulty or recent change in your habits of sleep, diet, exercise? No     Yes    Describe:

Any recent, significant weight changes? No        Yes Describe:

Present weight:      Height: 

FAMILY HISTORY

Check any of the following disorders which have occurred in your family.  This section does not refer to any problems that you yourself have had.

Cancer (specify)   

Diabetes                                                                 Obesity

Thyroid disorders                                                Psychiatric disorders

Heart disease                                        Infertility

Hypertension                                        Multiple Miscarriages

Blood clotting disorders                     Seizures

Tuberculosis

Baby with birth defects/retardation

Chromosome (genetic) abnormality

Other: (specify):

If you checked any of the above, please explain:

MENSTRUAL HISTORY

At what age did you begin to menstruate?

Have you ever gone more than three months without having a period?    

No   Yes     How long? (Mos./Yrs.)

Approximate dates when this occurred:

Are you normally: REGULAR? IRREGULAR?

Please describe: 

What is the average length of your menstrual cycle?  (Interval from first day of bleeding until the day before bleeding of the next cycle): 

Has this changed since puberty?      No       Yes

Explain

How many days does your period last? 

Is your flow  LIGHT MEDIUM HEAVY?        

Does this vary?    No      Yes

Please explain:  

Do you have pain during periods?   No       Yes

Please describe: 

Do you have pain between periods? No     Yes

Please describe:

Do you bleed between periods?         No   Yes

If yes, describe frequency and amount of blood loss:  

GYNECOLOGICAL HISTORY

Have you had regular GYN exams? No      Yes

Date of last exam:

Date and result of last pap smear:

Have you had regular breast examinations? No        Yes    

Date of last exam:

Date & findings of last abnormal exam:

Date & findings of last mammogram:

Have you ever had a milky discharge from one or both breasts?  No  Yes

If so, when?

Have you had a history of:  (If yes, please give date)

Chlamydia:

Gonorrhea:

Pelvic (tubal) infection:

OBSTETRICAL HISTORY

Not Applicable    (Continue on to next section)

                                                            Months                           Vaginal/
                                           Number     Date(s)    to conceive   Sex/Wt.     C-Section
Full term deliveries

(37 weeks or more):              

Premature deliveries):             

(Less than 37 weeks):              

 Number                   Dates  

Miscarriages                                                   

Induced Abortions                                            

Stillbirths                                         

Newborn Deaths                              

Ectopic Pregnancies:

Side     /         Date     /    Treatment 

Were any of your children born with congenital defects?   No    Yes

If yes, state which delivery and describe the congenital defect:

Dates of pregnancies with present husband/partner:

Number of living children from this marriage/relationship:

Did you have any pregnancies/children from a previous spouse/partner?: 

No  Yes     If yes, list dates of pregnancies:

And living children:

If applicable, dates of pregnancies through artificial insemination:

donor sperm only: living children:

CONTRACEPTION

NotApplicable (continue on to next section)

Please check any of the following methods of contraception you are currently using and/or have used in the past.  Fill in the dates of usage.

           Method                                        Dates of Usage

Birth control pills

   Type  

IUD 

Type      

Diaphragm     

Condom         

Jellies Foam   

Withdrawal    

Sterilization Male      Female           Other:

INTERCOURSE HISTORY

Frequency of intercourse: times per week: times per month:   N/A

Do you have any problems with intercourse?     N/A    No      Yes

If yes, describe your problems with intercourse:

Do you have noticeable discharge? N/A     No    Yes 

Please describe your discharge (color, consistency, presence of odor, itching, etc.):

Any changes in libido? N/A No  Yes

Any pain during or after intercourse?  N/A     No    Yes

Do you bleed during or after intercourse? N/A       No     Yes

REVIEW OF SYSTEMS

Check any of the following disorders you currently have or have a history of:

CENTRAL NERVOUS SYSTEM

Seizures

Migraine headaches

Other:

None:

ENDOCRINE

Diabetes                                               

Thyroid disease

Excessive growth of hair on various parts of the body

Hair loss                                                Unexplained rash

Rapid weight gain                Rapid weight loss

Excessive hunger/thirst      Other:

EENT

Eye disorders                        Double or blurry vision

Problem with sense of smell

Other:

RESPIRATORY

Shortness of breath             Asthma (date of last attack)

Bronchitis                              Pneumonia

Cough producing blood     Tuberculosis

Other:                

CARDIOVASCULAR

Chest pain                             Palpitations

Diagnosed with Rheumatic fever                     

Heart valve disease             High blood pressure

Mitral valve prolapse          Given prophylactic antibiotics

Other:

HEMATOLOGIC

Blood clotting disorder       Sickle cell anemia or trait

Thrombophlebitis                Other:

GASTROINTESTINAL

Nausea/Vomiting                 Blood in stool

Ulcers                                   Hepatitis

Constipation                        Spastic colon

Other:

GENITO-URINARY

Bladder infections (cystitis)

Kidney infection                  Vaginal infections

Frequent urination               Urinary Tract Infection

Other:

MUSCULO-SKELETAL

Unusual muscle weakness

Decreased energy/stamina

Rheumatoid arthritis

Lupus erythematosus

Other:

SKIN

Unexplained rash                 Acne

Skin Cancer                           Injuries

Dermatitis

Other: 

HUSBAND/PARTNER HISTORY

Are you married?  No     Yes

Duration of present marriage/relationship:

Has husband/partner initiated a pregnancy in a previous relationship?  

No    Yes

Please give dates and outcome of pregnancy:

Has husband/partner had a previous relationship where pregnancy did not occur even though no contraception was used?     No     Yes

How long a period was involved?

Any difficulty in achieving/maintaining an erection?    No    Yes

Any difficulty with ejaculation? (E.g., retrograds, premature)?     No    Yes

Any history of possible reproductive tract problem, (including dates) e.g.,

 Prostatitis,   Epididymitis, Orchitis,   Testicular tumor,   Injury to testes

Any history of transmissible disease?  No Yes

Gonorrhea     Chlamydia      Non-specific urethritis        Syphillis        

Any history or reproductive tract surgery?

 No     Yes   Please give procedure and date:

HUSBAND/PARTNER-MEDICAL HISTORY

Do you have any allergies?   No  Yes

Please specify:

Childhood illnesses-  Routine:

 chicken pox     measles mumps

Others: (Describe):

Your general health:  Excellent      Good            Fair       Poor

Do you drink alcohol?      Daily            Weekly    Monthly            > Never    

Have you ever been in a serious accident?  No         Yes 

(Describe):

Have you ever had a blood transfusion?   No  Yes

Approximate date(s):

List all significant medical illnesses requiring treatment.  Include dates and name of physician/hospital which husband/partner has experienced:

List all surgical procedures, approximate date and hospital which husband/partner has undergone:

Have you undergone a surgical sterilization procedure? No  YesIf so, please describe:

List current medications: State the name of medication, indication for its use, and how long medication has been taken.  Include both prescription and over-the-counter medication.

        Medication   /    Starting    /   Through    /   Amount    /   Indications

1. 

2. 

3. 

Does husband/partner smoke cigarettes?  No  Yes 

Number of packs per day: 

If husband/partner smoked in the past and has quit, give the approximate dates of smoking:    

Drug usage in past year:

Marijuana       Cocaine       Depressants       Stimulants  Other:

State the substances and extent of exposure:  

Any difficulty or recent change in your habits of sleep, diet, exercise?  

No  Yes

Please describe: 

Any recent illnesses or change in health?  No   Yes  

Please describe: 

Any recent, significant weight changes?  No   Yes    

Please describe:

Present weight:     Height:

Has husband/partner been exposed to: 

 high temperatures      hot tubs       Radiation  

Chemicals    Toxic substances

PAST INFERTILITY EVALUATION

Months Infertile prior to coming to Genesis Fertility:

                                                           Date(s) / Result(s):

Husband/partner semen analysis:    

Temperature charts:    

Postcoital test (Huhners):     

Endometrial biopsy:     

X-ray of tubes:           

Diagnostic laparoscopy:        

Hysteroscopy:             

Hormonal tests:          

Chromosomal studies: 

PRIOR FERTILITY TREATMENT

Not Applicable  (Continue on to next section)

Number of prior non-ART gonadotropin treatment cycles (both with and without intrauterine insemination):

Number of prior fresh ART cycles (this number should include any cancelled cycles):

IVF (in vitro fertilization)

Other (GIFT, ZIFT, or TET)

Number of prior frozen embryo transfer procedures (please do not include cancelled cycles): 

Medications taken:

Please feel free to use the following “comments section” for any additional information you feel may be helpful in your infertility evaluation:

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