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Coastal ahec/patnt hist female

Nature of present employment (title, brief description) 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? .
List the forms and frequency of regular vigorous exercise (swimming, cycling, running) and age you began: Do you have or have you ever had (check all that apply): Have you ever been treated for cancer? .
Have you ever received X-rays to the pelvic area for therapy or diagnosis? .
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 diagnosis: Do you use or have you ever used (check all that apply); Alcohol - How many glasses per week do you usually drink? Wine 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: 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? Are cramps present before, during or after your period? Do you have to take pain medication for cramps? .
Do you bleed or spot between periods? .
How many pregnancies (including abortions) have you had? Were there any complications during or after your pregnancies? .
Did your mother have any difficulty with conception or pregnancy? .
How long have you now been trying to get pregnant? Did your mother take diethylstilbestrol (DES) when she was pregnant with you? .
What form of contraception do you use now or have you used in the past? Check all that apply: For each contraceptive method used, specify length of use and reason for discontinuation: If you’ve 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? .
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: Have you been treated for infertility before? .
What drugs have you taken for infertility? Check all that apply clomiphene citrate (Serophene®, Clomid®) Which of the following tests have you had performed? Check all that apply and the results if known: Hormonal Assays (FSH, LH, prolactin, estrogen DHEA-S, testosterone, progeterone) Have you ever had surgery for tubal reversal .
Have you ever had surgery for lysis of adhesions? .
Have you ever had cervical conization or cautery? .
Have you ever had any other surgery (D&C, ovarian, appendectomy, thyroid? .
Have you ever undergone artificial insemination or in vitro fertilization? .
Is your partner seeing a doctor for evaluation of infertility? .
If yes, specify physician name and location: Does the doctor feel that your partner has an infertility problem? .
If yes, what is the diagnosis and how is he being treated? Has he ever fathered a child with another woman? .

Source: http://www.coastalahec.org/patient_svs/documents/female-patient-history.pdf

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