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? ____________________________________________________________________________________________________
TJUH Therapeutic Interchange To Jump to the page of the Therapeutic Interchange press ‘CTRL’ and click on the heading in the table of contents, or the name in “Index by Class” or “Index by Drug” lists Contents Index by Class TJUH Therapeutic Interchange Index by Drug TJUH Therapeutic Interchange TJUH Therapeutic Interchange Antihistamine Ag
Call for Papers for a Special Issue ENTREPRENEURSHIP AND STRATEGY IN EMERGING ECONOMIES Garry D. Bruton, Texas Christian University Igor Filatotchev, City University of London and Economics University of Vienna Steven Si, Tongji University and Bloomsburg University of Pennsylvania Introduction and Special Issue Background The world is undergoing a rapid economic shift as firms i