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Microsoft word - new patient questionnaire2.doc

Date:_____________ Name:_______________________________________ Age/DOB____________ Marital Status: Single______ Married ______ Prior Marriage: Wife______ Husband ______ Referred by:_________________________________________________________________________
I. OBSTETRICAL HISTORY


II. FERTILITY HISTORY

How many years have you been attempting pregnancy? If married, how many years have you been married? Have you ever been evaluated for infertility? What cause(s) of infertility was diagnosed? Previous Fertility Treatment
Which drugs have you taken or treatments done for infertility? _____ None Clomiphene Citrate (Clomid, Serophene) ____ Progesterone supplements ____ Letrozole (Femara) ____ Artificial Insemination: # cycles ____ ____ In Vitro Fertilization: # cycles_____ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ Ovulation Assessment
Date of last normal period ___________________________ Do you have regular, cyclic, predictable, spontaneous periods? If yes, at what interval (1st day to 1st day)_________________________________________ If no, explain:______________________________________________________________ S:\New Patient Packets\New Patient Questionnaire\01-19-06 Do you ever “skip” periods? Explain:______________________________________________ Yes No Do you experience mid-cycle or premenstrual spotting on a regular basis? Yes No __________________________________________________________________ Have you ever taken birth control pills? If yes, what ages?______________________________ Yes No When (Month/Year) did you last take birth control pills?___________________________ Do you have any history of anorexia, bulimia (eating disorders)? ________________________ Yes No Do you exercise? ______hrs/week Activities _______________________________________ Yes No Thyroid Disease
Do you have (or had) thyroid disease? Explain: ______________________________________ Yes No Galactorrhea/Hyperprolactinemia
Milky or Watery (clear), spontaneous or manually expressed (only) Explain: _____________________________________________________________________ Hirsutism
Do you have any hair growth you consider abnormal? (please circle) face, upper lip, chin, Yes No If yes, how long has this been present? years If yes, how often do you shave, use depilatory creams, pluck, or undergo electrolysis? Explain:_____________________________________________________________________ Ovulation Monitoring/Testing

Can you tell when you are ovulating based on your physical symptoms? Yes No Have you conducted any of the following tests? Have you used any ovulation predictor kits? If yes, which brands have you used? __________________________________________ _____________________________________________________________________ If yes, which cycle days do you typically surge?_______________________________ Uterotubal Assessment
Have you had a hysterosalpingogram or HSG (x-ray dye test of the uterus)? When: __________________________________________________________________ Have you had a sexually transmitted disease or an infection in your pelvis or fallopian tubes ? Yes No i.e., pelvic inflammatory disease, Chlamydia, Gonorrhea, Syphilis, or Herpes. Explain: _________________________________________________________________ Have you been diagnosed as having endometriosis? Explain:_________________________________________________________________ Have you been diagnosed as having uterine fibroids? Yes No Explain:_________________________________________________________________ S:\New Patient Packets\New Patient Questionnaire\01-19-06 Pelvic Pain
Do you have painful cramps with your periods? Do you take pain medication for cramps? Which one (s) _____________________________ Yes No Does this medication provide adequate relief? _______________________________________________________________ Cervical Assessment
Do you experience recurrent (> 2/year) yeast infections or bacterial vaginosis? Have you had a postcoital test? Results:___________________________________________ Yes No Have you had surgery on your cervix, i.e., biopsy or conization? How many times per week do you and your partner have intercourse? Male Factor Assessment
Has your husband sired previous pregnancies (including miscarriages)? Does your husband have any health problems? Does your husband take any medications on a chronic basis? Has your husband had genital surgery, or infections? S:\New Patient Packets\New Patient Questionnaire\01-19-06 III. CURRENT MEDICATIONS – Wife (include dosage, frequency, and any over-the-counter drugs)
____________________________________________________________________________________ ___________________________________________________________________________________________ IV. MEDICATION ALLERGIES – Wife only
________________________________________________________________________________
Other allergies:_______________________________________________________________________________ V. YOUR PAST MEDICAL HISTORY
Check any conditions that you had or currently have:

Mitral Valve Prolapse ( ) ( ) Diabetes ( ) ( ) Stroke ( ) ( ) Mental Disorder ( ) ( ) Thyroid Disease ( ) ( ) Liver or Gallbladder Disease ( ) ( ) Arthritis ( ) ( ) Heart Disease ( ) ( ) High Blood Pressure ( ) ( ) Asthma ( ) ( ) Rheumatic Fever ( ) ( ) Chronic Bronchitis ( ) ( ) Ulcers ( ) ( ) Phlebitis or Blood Clots ( ) ( ) Blood Disorder ( ) ( ) Crohn’s Disease ( ) ( ) Seizures ( ) ( ) Broken Bones ( ) ( ) Ulcerative Colitis ( ) ( ) Kidney Disease ( ) ( ) Migraine Headaches ( ) ( ) Explain: ____________________________________________________________________________ ___________________________________________________________________________________ Please list other physicians currently involved with your care: _________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ VI. SURGICAL HISTORY
Surgeries/Hospitalization (dates):____________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ VII. GYNECOLOGIC HISTORY:
Date of last pap smear________________________ …Normal …Abnormal Date of last mammogram_____________________ …Normal …Abnormal … Never done Do you have a history of: Yes No Explain:
( ) ( ) ______________________________________ ( ) ( ) ______________________________________ Previous IUD use ( ) ( ) ______________________________________
DES exposure in utero ( ) ( ) ______________________________________
VIII.SOCIAL HISTORY

Alcohol: (circle one) Drinks per: Day _____Week _____ Month _____Year _____ Non-drinker _________ Caffeine: Number of beverages per day _________ Illicit drugs: _________________________________ S:\New Patient Packets\New Patient Questionnaire\01-19-06
IX. FAMILY HISTORY:

Check if any blood relative has had: What is your ethnic background?
Yes No Yes No
Down Syndrome ( ) ( )
Hydrocephalus (water on the brain)( ) ( ) Age Living Deceased Health or Cause of Death X. REVIEW OF SYSTEMS
Do you have (please circle):
Constitutional: fever, chills, sweats, loss of appetite, rapid weight loss, fatigue, or NONE
Eyes: vision loss, change in vision, or NONE Ears/Nose: poor sense of smell, decreased hearing, or NONE Throat: difficulty swallowing, chronic sore throat, hoarseness, or NONE Cardiovascular: chest pains, palpitations, fainting spells, or NONE Respiratory: chronic cough, shortness of breath, produce blood with coughing, wheezing, or NONE GI: nausea, vomiting, abdominal pain, changes in stool, diarrhea, constipation, or NONE GU: recurrent (>2/year) bladder infections, blood in urine, incontinence, or NONE Psychiatric: depression, anxiety, or NONE XI. COMMENTS:
____________________________________________________________________________________________________
____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ S:\New Patient Packets\New Patient Questionnnaire2\01-19-06

Source: http://www.dallasfertility.com/pdfs/2%20New%20Patient%20Questionnaire.pdf

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