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Patient Portal
Female Patient History
"
*
" indicates required fields
I. Identify Information
Date
*
DD dash MM dash YYYY
Name
*
First
Partner's Name
*
First
Address
*
Telephone Number (Day)
*
Telephone Number (Evening)
*
Date of Birth
*
DD dash MM dash YYYY
Partner's Date of Birth
*
DD dash MM dash YYYY
Duration of Relationship
*
Duration of Identity
*
Insurance Company
*
Insurance I.D.
*
Nature of present employment (title, brief description)
Title
*
First
Brief Description
*
III. Medical History
weight
*
Height
*
Blood Type (If Known)
*
Have you ever lost greater than 20 pounds of weight in the last year
Yes
No
Do you follow a particular food diet or have any special dietary habbits
Yes
No
If yes, specify
List the forms and frequency of regular vigorous exercise (Swimming, cycling, running) and the age you began
Exercise
Hours/Week
Age
Exercise
Hours/Week
Age
Have you ever had surgery in the pelvic surgery
Yes
No
If yes, specify date and type of surgery:
Have you ever received X-rays in the pelvic area for therapy or diagnosis?
Yes
No
If yes, explain:
Do you have or have you ever had (check all that apply):
Anemia
Appendicitis
Arthritis
BloodTransfusion
Breast Milky Discharge
Breast Soreness
Breast Tenderness
Chlamydia
Chronic Bronchitis
Chronic Headaches
Colitis
Color Blind
Diabetes
Dizziness
Endometriosis
Cancer ?
Epilepsy
Gallbladder Problems
Gonorrhea
Heart Disease
Hepatitis
Herpes
High Blood Pressure
Kidney Infection
Liver Problems
Loss of Balance
Measles: German
Measles: Regular
Mumps
Mumps with Testes Involved
Neurological Problems
Nongonococcal Urethritis
Parasitic Infection
Pneumonia
Prostatitis
Rheumatic Fever
Scarlet Fever
Seizures
Syphilis
Testes Infection
Testes Injury
Testes Tumor
Thyroid Problems
Tuber Culosis
Ulcers
Visual Disturbances
Any Allergies?
If Cancer? Specify
Any Allergies? List
have you ever been treated for cancer?
Yes
No
If yes, explain therapy
have you ever received X-rays to the pelvic area for therapy or diagnosis?
Yes
No
If yes, specify
Within the last year, have you taken any prescription medications?
Yes
No
If yes, list all prescriptions and problems for which you were tak'ng them:
Are you taking any over-the-counter medications on a regular basis?
Yes
No
If yes, list all médications and diagnoses:
Do you use lubricants for intercourse?
Yes
No
If yes, which one?
Do you douche before or after intercourse?
Yes
No
IV. FAMILY HISTORY
Is there a family history of infertility?
Yes
No
If yes, who (list all members and relationship to you):
Is there a history of hormonal disorders in your family?
Yes
No
If yes, who and what type:
IV. HISTORY of FERTILITY THERAPY
Have you been treated for infertility before?
Yes
No
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®)
hMG (Pergonal®)
estrogens
progesterone
prednisone (or cortisone-like drugs)
antibiotics
GnRH or LHRH (Factrel®)
hCG (Profasio, A.P.L.0)
bromocriptine (Parlodel )
danazol (Danocrine )
urofollitropin or FSH (Metrodin )
None
Other - Specify
Others? Specify
Which of the following tests have you had performed? Check all that apply and the results if known:
BBT
BBT
When?
Results:
Postcoital Test
Postcoital Test
When?
Results:
Hormonal Assays (FSH, LH, prolactin, estrogen DHEA-S testosterone, progesterone
Hormonal Assays (FSH, LH, prolactin, estrogen DHEA-S testosterone, progesterone
When?
Results:
Endometrial Biopsy
Endometrial Biopsy
When?
Results:
Hysterosalpingogram
Hysterosalpingogram
When?
Results:
Ultrasound
Ultrasound
When?
Results:
Antibodies
Antibodies
When?
Results:
Laparoscopy, Hysteroscopy
Laparoscopy, Hysteroscopy
When?
Results:
Mycoplasma/Chlamydia Cultures
Mycoplasma/Chlamydia Cultures
When?
Results:
Thyroid Tests
Thyroid Tests
When?
Results:
Others-Specify
Have you ever had surgery for tubal reversal?
Yes
No
If yes, specify dates:
Have you ever had surgery for lysis of adhesions?
Yes
No
Have you ever had cervical conization or cautery?
Yes
No
Have you ever had any other surgery (D&C, ovarian, appendectomy, thyroid)?
Yes
No
If yes, please specify:
Have you ever undergone artificial insemination or in vitro fertilization?
Yes
No
If yes, using partner or donor sperm?
Is your partner seeing a doctor for evaluation of infertility?
Yes
No
If yes, specify physician name and location:
Does the doctor feel that your partner has an infertility problem?
Yes
No
If yes, what is ihe diagnosis and how is he being treated?
Has he ever fathered a child with another woman?
Yes
No
If yes, when?
