Microsoft word - female history.doc

FEMALE PATIENT HISTORY
Date _______________ Name_____________________________________________________ Weight___________________ Height ____________________ Blood Type (if known) _________________ How long have you been trying to get pregnant? Past history: (if applicable):
Year Born Miscarriage? Abortion? Ectopic? Fert drugs Current Preterm Preterm How many Pregnancy-induced required? partner? labor? delivery? weeks? hypertension? 1st pregnancy __ ___ ______ ________ _______ ______ ________ ______ ______ ______ __________ __________ 2nd pregnancy __ ___ ______ ________ _______ ______ ________ ______ ______ ______ __________ __________ 3rd pregnancy __ ___ ______ ________ _______ ______ ________ ______ ______ ______ __________ __________ 4th pregnancy __ ___ ______ ________ _______ ______ ________ ______ ______ ______ __________ __________ 5th pregnancy __ ___ ______ ________ _______ ______ ________ ______ ______ ______ __________ __________ Has your partner ever fathered a child? (circle) If yes, how many children/pregnancies?____________________________________________________ Infertility History:
Have you ever been treated for infertility?_________________________________________
If yes, have you used infertility medications (ie: follicle stimulation hormone-FSH or Clomid)? _________ How many cycles of medications? _______________________________________________________ Have you ever undergone an IVF cycle? (circle) If yes, when and what were the results? _____________________________________________________ Menses:
When was the first day of your last period?
If no, how many times per year do you menstruate? Are your periods mild, moderate, severe, or none in terms of pain? Do you have any issues with bowels during menses? (diarrhea, constipation, dumping syndrome)?
____________________________________________________________________________________
Have you ever used an ovulation predictor kit? (circle) YES
If yes, when in your cycle do you have a positive surge? _________________________________________ Procedure History:
Have you had any pelvic surgery(ies) performed? (circle)
If yes, please explain: _____________________________________________________________________
D & C procedure(s)? YES NO If yes, how many and when? _____________________________________
Have you ever had a hysterosalpingogram (HSG) performed? (circle) YES
If yes, who performed the HSG and what were the results? _______________________________________
Have you had a tubal ligation? YES NO Have you been diagnosed with endometriosis? YES NO
Please list all types and dates of surgeries you have undergone:___________________________________
______________________________________________________________________________________
Pap History:
When was your last pap smear done? ____________________Where? ____________________________
Was it normal or abnormal? ________________________
Have all of your paps been normal? (circle) Have you had any lab work done? (If yes, please describe tests, results, and where performed):__________
_______________________________________________________________________________________
Medical History:
Are you currently experiencing any medical problems? (If yes, please describe):__________________________
__________________________________________________________________________________________
Family history of blood clotting disorders?
Anyone with cystic fibrosis in your family? (circle) Have you ever been treated for cancer? (circle) If yes, please explain: _____________________________________________________________________ C:\Users\cory.colt\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\LVR8VJ5V\Female History.doc Do you currently have, or have you ever had (circle all that apply):
Anemia

What medications do you regularly take? (Prescription and/or over the counter drugs; include dosage):_____________
_______________________________________________________________________________________________
What local pharmacy do you prefer?___________________________________________________________________
Do you currently or have you ever, used:
Alcohol? How many drinks per week?_______________________________________________
Cigarettes? How many packs per day?______________________________________________
Illicit or recreational drugs?________________________________________________________
Allergies? (circle) YES NO If yes, please list:_____________________________________________
Countries of origin:
Mother’s
Ethnic background (circle):
African

Ethnic Group:
Have you ever been tested for:
Mediterranean (Greek or Italian) or Hispanic Caucasian, _____________________________________________ Would you like to take the test(s) recommended for your specific ethnic group? (Circle) YES
Are you related to your spouse (consanguinity)? (Circle) Fragile X testing is recommended if the exact etiology of the mental retardation is unknown. Would you like this testing performed? (Circle) C:\Users\cory.colt\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\LVR8VJ5V\Female History.doc

Source: http://www.idahofertility.com/idaho/documents/Female_History.pdf