Microsoft word - fertility patient history_2012.doc

FERTILITY
HISTORY FORM

1. IDENTIFYING INFORMATION
Name _________________________________________ Partner’s Name ___________________________ Number of years together __________________________ Primary MD ____________________________________ Reproductive Endocrinologist: ______________________
Reasons you are coming to see us: _________________________________________________________________
_____________________________________________________________________________________________
2. HISTORY/LIFESTYLE

Your occupation: _________________________
Partner’s occupation: _____________________________ Height: ___________ Weight: _____________ Previous marriage:  yes  no Children from previous marriage?  yes  yes  no Children from previous marriage?  yes Exercise type: ___________________________________________ Frequency/week: ________________________ Stress level (scale of 1 to 10): ________________ Alcoholic drinks/week: _____________________ Tobacco use # of cigarettes: _________________ Diet:  Poor How many meals/day? ______________

3. PREGNANCY HISTORY

Are you currently pregnant?
maybe

4. CONTRACEPTIVE USE
Reason Discontinued

1. _________________________________ ___________________ ___________________________________________
2. _________________________________ ___________________ ___________________________________________
3. _________________________________ ___________________ ___________________________________________
5. MEDICATIONS List all prescriptions, over-the-counter drugs, supplements, & herbs used during the past year
Medication
Dose/Frequency
Dates of Use
Reason Prescribed

1. _________________ ___________________ _______________________ ________________________________
2. _________________ ___________________ _______________________ ________________________________
3. _________________ ___________________ _______________________ ________________________________
4. _________________ ___________________ _______________________ ________________________________
5. _________________ ___________________ _______________________ ________________________________
6. _________________ ___________________ _______________________ ________________________________
HEALING RESPONSE ACUPUNCTURE 362 NE CLAY AVE FERTILITY
HISTORY FORM
6. ALLERGIES

Drug or Substance
Reaction

1. _________________________________ ___________________ ___________________________________________
2. _________________________________ ___________________ ___________________________________________
3. _________________________________ ___________________ ___________________________________________
7. MENSTRUAL/HORMONAL

Age of first period: ______________
Date of last two menstrual periods: _____/_____/_____ and _____/_____/_____ Do you menstruate regularly?  yes  no If yes, your cycle varies from ____ to ____ days How many days does your period last? ________________ During your period, the flow is: Light Do you have any of the following symptoms after menstruation?  night sweats  others: ___________________________ How do you know? ____________________________________________________________________________ Pelvic pain/cramps:  none  during menses  before menses  during intercourse  with bowel movements  with urination Pelvic pain/cramps are:  mild moderate severe  worsening  improving  no change  in midline  on right side  on left side Frequency of intercourse: __________________________ Do you need to use a lubricant? Do you have intercourse during menstruation?  yes  no Do you have milk or discharge from your breasts?  yes  no If you have a hormonal disorder, please specify type and treatment: _____________________________________________ HEALING RESPONSE ACUPUNCTURE 362 NE CLAY AVE FERTILITY
HISTORY FORM
8. GYNECOLOGIC/INFECTIOUS HISTORY
Do you have or have you had?
 Abnormal pap smear
 Cancer of Uterus/Ovaries/Cervix  Genital herpes
9. FERTILITY THERAPY HISTORY
Have you been treated for infertility previously?  yes  no
If yes, who was your physician? _________________________
What cause of infertility was diagnosed? ______________________________________________________________
What drugs have you taken for infertility?
 Other ____________________________________ Which of the following tests have you or your partner had performed? Results: ___________________________________________ Results: ___________________________________________ Results: ___________________________________________ Results: ___________________________________________ Results: ___________________________________________ Results: ___________________________________________ Results: ___________________________________________ Results: ___________________________________________ Results: ___________________________________________ Results: ___________________________________________ Results: ___________________________________________ Results: ___________________________________________ Results: ___________________________________________ Results: ___________________________________________ Results: ___________________________________________ Results: ___________________________________________ Results: ___________________________________________ Results: ___________________________________________ Results: ___________________________________________ Results: ___________________________________________ Results: ___________________________________________ Results: ___________________________________________ Results: ___________________________________________ Results: ___________________________________________ Results: ___________________________________________ Results: ___________________________________________ Results: ___________________________________________ HEALING RESPONSE ACUPUNCTURE 362 NE CLAY AVE FERTILITY
HISTORY FORM
 Other: _________________________________________________________________________________________________________ Have you ever undergone Artificial Insemination (IUI) or In Vitro Fertilization (IVF)?  yes  no If yes,  partner  donor sperm Clomid:  yes  no Name of medications:____________________________________ Dates: _______________________________________________ Dates: _______________________________________________
10. FAMILY HISTORY
In your extended family, living or deceased, did any of the following occur before the age of 65?:
Disease:
Family Member:
 Miscarriage which trimester? ________ Thank you for taking the time to fill out this form, these answers will help determine how we can best help you.
HEALING RESPONSE ACUPUNCTURE 362 NE CLAY AVE

Source: http://www.healingresponse.net/wp-content/uploads/2012/07/Fertility_Patient_History.pdf