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Female history sheet

FEMALE HISTORY SHEET
I. IDENTIFYING INFORMATION

Name: _____________________________________ Partner’s Name ___________________________________________________________ Address: ____________________________________________________________________________________________________________ Telephone Number – Day ( ) ______________________ Evening: ( )_______________________ Cell( )_______________________ Date of Birth ___________ Partner’s Date of Birth_____________ Duration of Relationship________ Duration of Infertility __________________ Insurance Company ____________________________________ Insurance ID #: _________________________________________________ Nature of present employment (title, brief description) _________________________________________________________________________ ____________________________________________________________________________________________________________________
II. MEDICAL HISTORY
Weight _________ Height ___________ Blood Type (if known) _____________________________________________ Have you lost greater than 20 pounds of weight in the last year? …………………………………………………………………. Do you follow a particular food diet or have any special dietary habits? …………………………………………………………. If yes, specify: ______________________________________________________________________________________________________ List the forms 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: ___________________________________________________________________________________________ Have you ever had another type of surgery?…………………………………………………………………………………………. If yes, specify date and type: ____________________________________________________________________________________________
Have you or a relative ever had (check all that apply):

You Relative

You Relative
You Relative
  Cancer? Specify _________   High Blood Pressure _____________________________   Immunization: German Measles   Vaginitis (Trichomoniasis, yeast)   Loss of Balance
  Any Allergies: List_____________________ __________________________________________ Have you ever been treated for cancer? ………………………………………………………………………………………………. If yes, explain therapy _______________________________________________________________________________________________ Have you ever received X-rays to the pelvic area for therapy or diagnosis? ……………………………………………………… If yes, specify: _____________________________________________________________________________________________________ With the last year, have you taken any prescription medications? …………………………………………………………………. If yes, list all prescriptions and problems for which you were taking them: _______________________________________________________ ___________________________________________________________________________________________________________________
Are you taking any over-the-counter medications on a regular basis? ……………………………………………………………. If yes, list all medications and diagnoses: _________________________________________________________________________________ ___________________________________________________________________________________________________________________ Do you use or have you ever used (check all that apply):  Alcohol – How many glasses per week do you usually drink? Wine ______ Beer ______ Cocktails ______  Cigarettes – Number of packs per day ________  Illicit or Recreational Drugs (Marijuana, Cocaine, etc.). If you would feel more comfortable not writing anything down, please discuss this directly with Dr. Gianfortoni. Specify: _______________________________________________________________________ III. MENSTRUAL AND PREGNANCY HISTORY
Age at first period? _________ When was your last period? ___________________________________________________________________ Are your periods regular? ………………………………………………………………………………………………………………. If yes, what is the usual number of days between periods? __________________________________________________________________ If no, how many times per year do you menstruate? _________________________________________________________________________ What is the usual duration of your period? ______________Days Use:  Tampons?  Pads? Both _______________________________ Are cramps present before, during or after your period? _______ Are cramps:  Mild  Moderate  Severe _____________________ 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? __________________________________________________________________ (year) Abortion? Miscarriage? Pregnancy? conceive? alive? the father? Were there any complications during or after your pregnancies? …………………………………………………………………. If yes, explain: _____________________________________________________________________________________________________ Did your mother have any difficulty with conception or pregnancy? ………………………………………………………………. 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  Foams/Jellies  Condom  Rhythm  None  Other: ______________________________________________________________ For each contraceptive method used, specify length of use and reason for discontinuation: ____________ _______________________ _________________________________________________________________________ ____________ _______________________ _________________________________________________________________________
____________ _______________________ _________ ________________________________________________________________
If you’ve even been on oral contraceptives (pills), were your periods regular after stopping the pills? How m any times per week do you and your partner have sexual intercourse? _____________________________________________________ How many times do you have intercourse around ovulation? ___________________________________________________________________ Is intercourse painful or difficult for you? ……………………………………………………………………………………………… Do use lubricants for intercourse? ……………………………………………………………………………………………………. If yes, which one? ___________________________________________________________________________________________________ Do you douche before or after intercourse? …………………………………………………………………………………………. V. FAMILY HISTORY
Is there a family history of infertility? ………………………………………………………………………………………………… If yes, who (list all members and relationship to you) ________________________________________________________________________ __________________________________________________________________________________________________________________ Is there a history of hormonal disorders in your family? …………………………………………………………………………. If yes, who and what type: ____________________________________________________________________________________________ _________________________________________________________________________________________________________________ VI. 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, Colmid)  prednisone (or contisone-like drugs)  Other – Specify ____________________________________________________ Which of the following tests have you had performed? Check all that apply and the results if known: Results: ___________________________________________ Results: ___________________________________________  Hormonal Assays (FSH, LH, prolactin, estrogen, DHEA-S, testosterone, progesterone) Results: ___________________________________________ Results: ___________________________________________ Results: ___________________________________________ Results: ___________________________________________ Results: ___________________________________________ Results: ___________________________________________ Results: ___________________________________________ Results: ___________________________________________  Other – Specify ___________________ Results: ___________________________________________ Have you ever had surgery for tubal reversal? …………………………………………………………………………………………………  If yes, specify dates: ________________________________________________________________________________________________ Have you ever had surgery for lysis of adhesions? ……………………………………………………………………………………………  Have you ever had cervical conization, cautery, cryosurgery or LEEP?….…………………………………………………… ……….  Have you ever had any other surgery (D&C, ovarian, appendectomy, thyroid)? ……………………………………………. ………….  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 for evaluation of infertility? …………………………………………………………………………………….  If yes, specify physician name and location: ______________________________________________________________________________ Does the doctor feel that your partner has an infertility problem? ………………………………………………………………………………  If yes, what is the diagnosis and how is he being treated? ___________________________________________________________________ Has he ever fathered a child with another woman? …………………………………………………………………………………………….  If yes, when? ______________________________________________________________________________________________________

Source: http://www.lifesourcefertility.com/docs/LifeSource_Fertility_female_history_sheet.pdf

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