I and rm questionnaire

PATIENT INFORMATION/QUESTIONNAIRE
Please complete and return this form to: Cohen Center
Also, please arrange to have a copy of your previous medical records and the films of your Hysterosalpingogram (HSG), if applicable, sent to Cohen Center. No appointment will be made unless the records and films are available for the physician. You may call approximately one week after having this information sent to confirm our receipt of your records and to see if an appointment can be scheduled.
FOR OFFICE USE ONLY
New Patient Questionnaire (IRM) – Page 1 Name (Female):
(For example: 5 days bleeding/28 days between ? 5/28) New Patient Questionnaire (IRM) – Page 2 Name (Female):
Has there been any major weight loss or gain recently: Since the age of 16 your highest
and lowest
From the age of 16 to the present, have you participated in any of the following activities: drill team dance running/jogging aerobic dance other Please give a brief description of the type and level of exercise you have participated in Are you frequently hot or cold (circle one) when people around you are comfortable. Any known drug allergies:
New Patient Questionnaire (IRM) – Page 3 Name (Female):
Personal Medical History:
Medication(s) you currently take and dosage(s) per day: List any herbs you currently take and dosage(s) per day: New Patient Questionnaire (IRM) – Page 4 Name (Female):
Family history:

Genetic Screening Tests:
Are either you or your husband from:
If yes, have you been tested for Tay Sachs carrier status? If yes, have you been tested for sickle cell trait? 3) Italian, Greek, or Mediterranean ancestry? If yes, have you been tested for beta thalassemia minor? 4) Philippine or Southeast Asian ancestry? If yes, have you been tested for alpha thalassemia minor? Have you or your husband ever been tested for cystic fibrosis
Previous testing and treatments:

Name of Test
New Patient Questionnaire (IRM) – Page 5 Name (Female):
Previous testing and treatments, continued:
Name of Test
Have you ever had:
Have you ever had:
Have you ever had:
Artificial Insemination (Husband’s sperm): Medication_________ # of ampules____ Medication_________ # of ampules____ Medication_________ # of ampules____ # of follicles Please add additional cycles, if applicable, on the back of this sheet or print additional copies of this page
Please include ALL In Vitro LAB RECORDS
New Patient Questionnaire (IRM) – Page 6 Name (Female):

Have you ever used:
Clomiphene Citrate (Clomid or Serophene): Fertility (ovarian stimulation) injections: GnRH antagonists (Antagon or Cetrotide): Please list previous surgeries or hospital admissions (date and procedure), including previous laparotomies: Please give a personal summary (treatment goals and objectives): New Patient Questionnaire (IRM) – Page 7 *If you are seeking treatment for Recurrent Miscarriage please complete the following section for each miscarriage. If not,
please skip to the male partner’s information section:

Name (Female):
Was a heartbeat present? Yes No Spontaneous Loss or D & C Chromosome analysis? Yes No (if yes, please include results) Infection or fever after loss or D&C? Yes No Length of antibiotics post Loss/D&C _______days Stimulation before pregnancy? Yes No If yes, Clomiphene or Injectables If injectables, what type? Progesterone therapy? Yes No if yes, did you commence progesterone therapy before or after
If yes, what type of progesterone did you take? During your pregnancy did you use anticoagulants? Yes No If yes, Heparin Aspirin Lovenox Did you use steroids? Yes Did you have gammaglobulin infusions? Yes No If yes, how many and what dosages
What hormonal measurements were taken during your pregnancy?
Name of Test
Comments or additional information about this pregnancy Please fill out one sheet for each miscarriage. Print out as many sheets as you need. New Patient Questionnaire (IRM) – Page 8 Name (Male):
Number of years attempting conception with this partner: Any prior inguinal or testicular surgeries, e.g. hernia repair, varicocele: Has there been any major weight loss or gain: From the age of 16 to the present, have you regularly participated in: Please give a brief description of the type and level of exercise you have participated in Any known drug allergies:
New Patient Questionnaire (IRM) – Page 9 Name (Male):
Vocational Hazards: Gases Toxins Chemicals Insecticides Other poisons Personal Medical History:
Medication(s) you currently take and dosage(s) per day: List any herbs you currently take and dosage(s) per day: Family history:
New Patient Questionnaire (IRM) – Page 10 Name (Male):

Have you ever had:
Have you ever been on any medication to increase your sperm count or motility: Please list previous surgeries or hospital admissions (date and procedure): Please give a personal summary (treatment goals and objectives): New Patient Questionnaire (IRM) – Page 11

Source: http://www.briancohenmd.com/IRM%20Questionnaire.pdf