Final if quest 4-5-09

Confidential
Fertility Questionnaire
JAN RYDFORS MD FACOG, ARON SCHUFTAN MD FACOG
401 Warren Street, Suite # 300, Redwood City, CA 94063
Please complete and bring this questionnaire with you to your first visit.
MEDICAL ALLERGIES
Which drugs or medicines are you al ergic or sensitive to? PATIENT INFORMATION

Name:_______________________________________________________________________________________
Address:______________________________________________________________________________________ Phone: Day (___) ____- ______ Ethnic Group/Race: ____________________
Emergency Contact: _________________________ Relationship: __________________ Phone: (____) ____- _____________
SPOUSE/SIGNIFICANT OTHER INFORMATION

Name of Spouse/Significant Other: __________________________________________________________________
Age: ________________
Phone numbers: Day (___) ____- ______________ Evening (___) ____- ____________ Cel (___) ____- ______________ Ethnic Group/Race: __________________________ Occupation: ________________________________ Confidential
Fertility Questionnaire

GYNECOLOGICAL HISTORY

How old were you when you had you first period ______
How frequently do your periods come? Every ___days
How long do your periods last? _____days. When did your last period start? ______
Was there a time in the past, when you cycles were irregular while not on the “Pil ”? If so, please describe: ____________________________________________________ Have you ever taken the “Pil ”?  Yes  No If so, for how many years in total: ________________________________________ Do you experience cramping with your periods?  Yes  No If yes, when during your cycles do you have pain (check al that apply):  Before  During  After How would you describe the cramps?  Mild  Moderate  Severe Do you take pain medication for the cramps?  Yes  No If yes, specify medication: _____________________________________ Do you bleed or spot between periods?  Yes  No If yes, please describe:______________________________________________ Have you ever had an abnormal Pap smear result? ________ If yes, what therapy was required:  Cryotherapy (freezing of cervix)  Laser therapy  Cone biopsy  LEEP  Other: _____________________________________ Have you ever had any of the fol owing infections involving any part of the reproductive tract? (Check al that apply)  Chlamydia  Trichomonas  Gonorrhea  Herpes  Genital warts What treatment did you receive? __________________________________Year:____ Do you have pain with intercourse?  Never  Sometimes  Frequently  Always If yes, does the pain remain in your lower abdomen or back after intercourse if over?  Yes  No if yes, for how many minutes? : ______ How frequently do you and your partner have intercourse? _____Per  week  month How frequently do you and your partner have intercourse around ovulation? Confidential
Fertility Questionnaire
Do you usual y use lubrication during intercourse?  Yes  No If yes, please specify: _____________ Have you experienced any difficulties with intercourse that may be contributing to not get ing pregnant?  Yes  No If yes, please explain: _________________________________________ ________________________________________________________________________ Have you ever used contraception in the past?  Yes  No if yes, please check al that apply:
 Contraceptive pil s  Condoms  IUD  Foam/Sponge  Rhythm
 Withdrawal  Other: __________________________________________
PAST FERTILITY EVALUATION

How long have you and your partner been attempting to achieve pregnancy? __________
Have you been using temperature charts?  Yes  No If yes, for how long?____ ____ months Have you been using urine ovulation predictor kits?  Yes  No if yes, what kind and for how long? _________________________________ Have you ever tried to achieve a pregnancy with a different partner  Yes  No Have you ever conceived with a dif erent partner?  Yes  No Has your male partner ever got en someone else pregnant?  Yes  No Have you been treated for infertility previously  Yes  No If yes, where & when: _____________________________________________ What was the cause of infertility? _______________________________________________ Which of the fol owing tests have already been performed?  Infection test (mycoplasma,Chlamydia)  Postcoital test  Endometrial biopsy  Hysteroscope  Hormonal tests (FSH, Prolactin, TSH)  Antichlamydia Antibody  Ultrasound  Sonohysterogram  Hysterosalpingogram (HSG)  Antisperm antibody  Laparoscopy If done, indictate date and findings of the laparoscopy: ______________________________ Confidential
Fertility Questionnaire
Have you ever taken any of the medications listed below?  Clomiphene (Clomid,Serophene)  Letrozole (Femara)  Injectable gonadotropins (Menopur, Repronex, Humagon, Gonal-F, Fol istim)  HCG (Profasi, Pregnyl)  GnRH agonist (Lupron,Synarel,Zoladex)  Estrogens  Steroids (prednisone, dexamethasone)  GnRH Antagonist (Antagon)  Bromocriptine (Parlodel, Dostinex)  Baby aspirin  Glucophage (Metformin)  Progesterone  Heparin or Lovenox Have you ever had intrauterine inseminations (IUI)?  Yes  No if yes, for how many cycles? ____________ If yes, sperm specimen was provided by: (Check al that apply)  Partner  Donor How many cycles of IUI without any medications? ______________ How many cycles of IUI with Clomid? _________________________
How many cycles of IUI with Letrozole? _______________________
Home many cycles of IUI with Injectable medications (Menopur, Repronex, Humagon, Gonal-F, Fol istim): __________
Have you ever attempted in vitro fertilization?  Yes  No if yes, please put more details below:
_______________________________________________________________________________
_______________________________________________________________________________
OBSTETRICAL HISTORY
Have you ever been pregnant (including elective terminations, miscarriages, and births)?  Yes  No If yes, please describe: ______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
PAST MEDICAL HISTORY

Do you have or have you ever had any of the fol owing (check al that apply):
 Ovarian cysts  Anemia  Endometriosis  Gal bladder disease  Arthritis
Confidential
Fertility Questionnaire
 Heat or cold intolerance  Hair loss  Seizures  Mumps  High blood pressure  Hirsutism (excess hair growth)  Hot flashes  Vision problems
 Cystic Fibrosis  Diabetes  Breast (Nipple discharge)
 Colitis  Acne  Chronic headaches  Kidney or Liver problems  German Measles
 Regular Measles  Neurological problems  Autoimmune disease (e.g. Lupus Multiple Sclerosis, Arthritis)

PAST SURGICAL HISTORY

Have you ever had any surgeries besides laparoscopies in the past?  Yes  No

If yes, please indicate date, type, and findings of the surgery:
_____________________________________________________________________________

FAMILY HISTORY

Have any of these problems occurred in your family? Check al that apply and indicate relationship to you:
 High blood pressure _______________________  Ovarian cancer _______________________
 Infertility ________________________________  DES exposure in utero __________________
 Early menopause _________________________
 Heart disease ___________________________  Colon or Breast Cancer___________________
 Diabetes ________________________________  Thyroid disease _________________________
 Autoimmune disease (Lupus, Multiple Sclerosis, Rheumatoid Arthritis) _________________________


REVIEW OF SYSTEMS

Have you noted any significant:

Heat or Cold intolerance recently?  Yes  No
if yes, please explain: _____________________________________________
Unusual hair distribution changes or breast nipple discharge?  Yes  No
if yes, please explain: _____________________________________________
Significant weight change in the last year? If so, please describe how many lbs
and over what time: ____________________________________________

HABITS

Do you smoke?  Yes  No if yes, how many packs per day? ________
Confidential
Fertility Questionnaire
Do you drink alcohol?  Yes  No if yes, how many alcoholic beverages per week: __________ Do you smoke marijuana?  Yes  No if yes, how much per week: ________ Do you exercise regularly?  Yes  No if yes, please indicate type of exercise and estimate hours per week spent _________________________________________
_________________________________________
_________________________________________

MEDICATIONS:

Are you currently taking any prescription medications?  Yes  No
Medications Reason
_________________ _________________ ________________ _________________ Do any of you use herbal medications?  Yes  No if yes, types of medications used: _________________ Are you using Acupuncture or Chinese Herbal Medicine Currently?  Yes  No If yes, please describe: ___________________________________________ ______________________________________________________________ Confidential
Fertility Questionnaire

SECTION FOR MALE PARTNER FERTILITY EVALUATION
Which of the following test have already been performed?

 Semen analysis  Chromosome test  Blood tests (FSH,LH,Prolactin,Testosterone)
 Ultrasound of testis  Antisperm antibody test  Mycoplasma and Ureaplasma culture  Testicular biopsy Have you ever had any of the fol owing procedures done? (Check al that apply)  Varicocele repair  hernia repair  Prostate surgery  Testicular torsion repair  Testicular biopsy  Vasectomy reversal  Other (please specify): ______________________ Have you ever had any significant testicular injury?  Yes  No If yes, please describe: __________________________________________________________________________________ Have you ever taken any of the medications listed below?:  Clomiphene (Clomid,Serophene)  Proxeed  Testosterone  Viagra/Viagra like medications  GnRH agonist (Lupron,Synarel,Zoladex  Bromocriptine (Parlodel, Dostinex)  Other (please list): _________ Do you have or have you ever had any of the fol owing (check al that apply):  Cystic Fibrosis  Delay of puberty  Anemia  Arthritis  Cancer
 Autoimmune disease  Heat or cold intolerance  Seizures  Neurological problems
 High blood pressure  Vision problems  Testicular tumor
 Chronic headaches  Kidney /Liver problems  Colitis  Cystic Fibrosis  Diabetes
 Regular Measles  German Measles  mumps  Mumps with testes involved

PAST SURGICAL HISTORY

Have you ever had any surgeries in the past?  Yes  No
If yes, please indicate date, type, and findings of surgery:
____________________________________________________________________________

FAMILY HISTORY

Have any of these problems occurred in your family? Check al that apply and indicate relationship to you:
Confidential
Fertility Questionnaire
 High blood pressure ______________________ Ovarian cancer ___________________________  Infertility _______________________________  Prostate CA ______________________________
 Heart disease ___________________________  Colon/breast CA __________________________
 Diabetes _______________________________  Other __________________________________
REVIEW OF SYSTEMS

Have you noted any significant:
Heat/Cold intolerance recently?  Yes  No
if yes, please explain: _____________________________________________ Unusual hair distribution changes?  Yes  No if yes, please explain:_____________________________________________ Significant weight change in the last year?  Yes  No If so, please describe how many lbs and over what time: ______________________

HABITS

Do you smoke?  Yes  No if yes, how many packs per day? ________
Do you drink alcohol?  Yes  No if yes, how many alcoholic beverages per week: __________
Do you smoke marijuana?  Yes  No if yes, how much per week: ________
Do you take hot baths?  Yes  No if yes, how much per week: ________

Do you exercise regularly?  Yes  No if yes, please indicate type of exercise and
Estimate hrs per week spent:
___________________________________________
__________________________________________
MEDICATIONS:

Are you currently taking any prescription medications?  Yes  No
If yes, please describe:
Medications: ___________ Reason: _____________
Do any of you use herbal medications?  Yes  No
If yes, types of medications used: _________________________

Source: http://rwcdocs.com/final%20IF%20quest%205%2009.pdf