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NORTH HOUSTON CENTER FOR REPRODUCTIVE MEDICINE
FEMALE PATIENT HISTORY
IDENTIFYING
INFORMATION Date____________________

Name_______________________________________________Partner’s Name_____________________________________________________
Address______________________________________________________________________________________________________________
Telephone: Home_______________________________Work________________________________Cell_______________________________
Date of Birth_________________Partner’s Date of Birth________________Duration of Relationship___________Duration of Infertility_________
Nature of present employment (Title, brief description)_________________________________________________________________________
II. MEDICAL
Weight__________Height__________Blood type (if known)___________________________________________________ YES NO Have you lost greater than 20 pounds of weight in the last year?…………………………………………………………………………… ! Do you fol ow a particular food diet or have any special dietary habits?……………………………………………………………………. ! If yes, specify:____________________________________________________________________________________________ List the form and frequency of regular vigorous exercise (swimming, cycling, running) and age you began: Exercise:_______________Hrs/Week__________Age__________ Exercise: _______________Hrs/Week__________Age_________ _ Have you ever had pelvic surgery? ……………………………………………………………………………………………………………… !
If yes, specify date and type: _____________________________________________________________________________________________
_____________________________________________________________________________________________________________________
Do you have or have you ever had (check all that apply):
_____________________________ ! Ovarian Cysts ! Any medication Allergies? List: _____________________________________________________________________ ! Other Diagnoses: ________________________________________________________________________________ Have you ever-received X-rays to the pelvic area for therapy or diagnosis?………………………………………………………………. ! ! If yes, specify: _____________________________________________________________________________________________ List all current medications, both prescription and non prescription_____________________________________________________ _________________________________________________________________________________________________________ Do you use or have you ever used (check all that apply) ! Alcohol – How many servings per week do you usual y drink? _______________________________________________ ! Cigarettes – Number of packs per day _______________ Number of years ____________________________________ ! Marijuana, Cocaine, etc. ____________________________________________________________________________ III. MENSTRUAL AND PREGNANCY HISTORY Age at first period?________________ When did your last period begin? ________________________________________ Are your periods regular?…………………………………………………………………………………………………………………………. ! What is the usual number of days between periods?_______________________________________________________________ What is the usual duration of your period? ______________________________________________________________________ Are cramps: ! Mild ! Moderate ! Severe ! Absent Do you have to take pain medication for cramps? ……………………………………………………………………………………………. ! If yes, specify medication: ___________________________________________________________________________________ Do you bleed or spot between periods? ………………………………………………………………………………………………………… ! How many pregnancies (including abortions) have you had? _______________________________________________________ When?
Were there any complications during or after your pregnancies? ………………………………………………………………………………. ! !
If yes, explain: ______________________________________________________________________________________________
How long have you now been trying to get pregnant? _______________________________________________________________
Did your mother take diethylstilbestrol (DES) when she was pregnant with you? ………………………………………………………………
IV.
CONTRACEPTIVE / SEXUAL HISTORY
What form of contraception do you use now or have you used in the past? Check all that apply: ! Pills Name: ____________________ ! IUD Name: ____________________ ! Diaphragm ! Withdrawal ! Condom ! Other: ___________________________________________________________________________________________________ When did you discontinue contraception? (Approximate date) _____________________________________________________________ Is intercourse painful or difficult for you? …………………………………………………………………………………………………………………… ! ! Do you use lubricants for intercourse? ……………………………………………………………………………………………………………………. ! ! If yes, which one? ________________________________________________________________________________________________ V. FAMILY
Is there a family history of: (if yes, specify) ! Diabetes___________________________________________________________________________________________________ ! ! ! Birth Defects________________________________________________________________________________________________ ! ! ! Cancer____________________________________________________________________________________________________ ! ! ! Heart Disease / Strokes _______________________________________________________________________________________ ! ! ! Blood clots or bleeding problems_________________________________________________________________________________ ! ! ! Hepatitis or liver disease_______________________________________________________________________________________ ! ! ! Infertility____________________________________________________________________________________________________ ! ! ! Inherited or genetic diseases____________________________________________________________________________________ ! ! HISTORY OF FERTILITY THERAPY
Have you been treated for infertility before?…………………………………………………………………………………………………………………… ! ! If yes, who was your physician?________________________________________________________________________________________ What cause of infertility was diagnosed?_________________________________________________________________________________ What drugs have you taken for infertility? Check all that apply” ! Clomiphene citrate (Serophene, Clomid) ! Other – Specify_______________________________________ ! None Which of the following tests have you had performed? Check all that apply and the results if known: ! Postcoital Test? When____________________Results:____________________________________________________________ ! Hormonal Assays ? When____________________Results:____________________________________________________________ (FSH, LH, Prolactin, Estrogen, DHEA-S, testosterone, progesterone) ! Hysterosalpingogram? When______________________Results:________________________________________________________ ! Laparoscopy? When _________________________Results: ___________________________________________________________ ! Hysteroscopy? When____________________Results:_________________________________________________________________ ! Thyroid Tests ? When____________________Results:_________________________________________________________________ Have you ever had surgery for tubal reversal?……………………………………………………………………………………………………………. . ! ! If yes, specify dates________________________________________________________________________________________________ Have you ever had surgery for infertility?…………………………………………………………………………………………………………………… ! ! Have you ever had cervical conization, cryo or leep?……………………………………………………………………………………………………… ! ! Have you ever had any other surgery? ……………………………………………………………………………………………………………………. ! ! If yes, please specify:______________________________________________________________________________________________ Have you ever undergone artificial insemination or in vitro fertilization?………………………………………………………………………………. ! ! If yes, using partner or donor sperm?__________________________________________________________________________________ Is your partner seeing a doctor evaluation of infertility? …………………………………………………………………………………………………. ! ! If yes, specify physician name and location:_____________________________________________________________________________ Has he ever fathered a child with another woman?………………………………………………………………………………………………………. ! ! If yes, when? ____________________________________________________________________________________________________

Source: http://www.nhcrm.com/female-patient-history-form.pdf

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