Microsoft word - dr shaykh infertility history form _2_

AMERICAN SOCIETY FOR REPRODUCTIVE MEDICINE
Infertility History Form
FOR OFFICE USE ONLY

IMPORTANT:
Please complete this form and
Bring it with you to your scheduled visit.
This form was developed by the American Society for Reproductive
Medicine to assist physicians and patients in obtaining a complete
infertility history. It consists of three parts:
Part I: Contact information
Part II: Your medical history
Part III: Your spouse/male partner’s medical history (if applicable)

PART I: CONTACT INFORMATION
First Name _________________________ Middle Initial _______ Last Name _____________________________ Age _______
Date of Birth (MM/DD/YY) _______/_______/_________ Occupation ________________________________________________
Home Street Address ______________________________________________________________________________________
City ___________________________ State __________ Zip/Postal Code _______________ Country ______________________
Indicate which number to call or leave messages.
Other _______________________________________________________
Spouse/Male Partner
First Name _________________________ Middle Initial ________ Last Name ____________________________ Age _______
Date of Birth (MM/DD/YY) ______/_______/_________ Occupation _________________________________________________ Home Street Address ______________________________________________________________________________________ City ___________________________ State _________ Zip/Postal Code ________________ Country ______________________ Indicate which number to call or leave messages.
Who referred you?
sician Notes
ysician Notes
Name ________________________________ Phone ( ) _________________ (for office use only
(for office use only) )
__________________________________________________________ Former Patient/Friend ____________________________________________________ ___________________________
Web Site ______________________________________________________________ Insurance (Name of Insurance) _____________________________________________ ___________________________
Who is your Ob/Gyn?
___________________________
Name __________________________________ Phone ( ) _______________ __________________________________________________________ ___________________________
Who is your Primary Care Physician?
___________________________
Name __________________________________ Phone ( ) _______________ __________________________________________________________ ___________________________

PART II: FEMALE HISTORY AND INFORMATION
Reason for Visit:
Other __________________________________________
What are your expectations for this visit? ________________________________________________________________________
What questions do you want answered at this visit? _______________________________________________________________
_________________________________________________________________________________________________________
Do you have any personal, ethical or religious objections to any of our tests or treatments, such as insemination, in vitro fertilization,
egg donation, sperm donation, masturbation to collect a semen sample, etc.?

How many months have you been having intercourse without using any form of birth control? _____________
Pregnancy Summary
* Total Number of ALL Pregnancies: _________
* Number of miscarriages (less than 20 weeks): __________ * Number of Ectopic/Tubal Pregnancies: ________ * Number of Elective Terminations (Abortions): __________ * Number of Full Term Deliveries: ________ Of these, how many were live births? ______ How many were stillborn? _______ * Any Pregnancies with Birth Defects? Yes – explain _____________________________________________________ Date Pregnancy
Months to
Treatments to
Delivery Type/D&C/
Ended or Delivered
Conception
Conceive
Complications
Partner?

Menstrual History
* Menstrual cycle pattern (check all that apply):
* Number of days between the start of one period to the start of the next period: _________ days * How many days of bleeding do you have? _________ days * Dates of the 1st day of your last 2 menstrual periods: ______/______/______; ______/______/______ * Age when you had your first period: ____ years old * Age when you first noticed: Breast development: ____ years old; Pubic hair: ____ years old; Underarm hair: ____ years old * How many periods do you have per year? ______ * Do you need medication to bring on a period? Yes – what type? ________________________ * If you do not have periods, at what age did you stop having them? ______ years old * Do you have severe cramping or pelvic pain with your periods? Yes: __Always __Sometimes __Recently __In the Past
Contraceptive History
Birth control pills – dates of use_________-complications? ___________________________ Injectable contraception (Depo-Provera®, Lunelle™, etc.) – dates of use______________-complications? _________________ Skin patch – dates of use___________-complications? _________________________ Tubal sterilization procedure (tubes tied) – date (month/year) ______/______ Tubes untied – date (month/year) ____/____ * Did your mother take DES when she was pregnant with you?
Sexual History
* How many times do you have intercourse per week? _____times per week
* Have you used over-the-counter ovulation kits to time intercourse? * Do you use lubricants (K-Y Jelly®, etc) during intercourse? Have you had any of the following sexually transmitted diseases or pelvic infections? Pap Smear History
* When was your last pap smear (month and year)? ______/______
* When was your last abnormal pap smear? ______ Have you undergone any procedures as a result of an abnormal pap smear?
Breast Screening History
Have you ever had a mammogram?

Medical History
* Are you allergic to any medications?
Yes (Please list and describe reactions) _______________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ * Are you allergic to any foods (peanuts, eggs, etc.)? Yes (Please list and describe reactions) ___________________ _________________________________________________________________________________________________________ * List any medications you are currently taking, including over-the-counter medicines:_____________________________________ _________________________________________________________________________________________________________ * Do you take any herbal medicines/vitamins or health food store supplements? _________________________________________________________________________________________________________ * Do you have any medical problem(s)? Yes (Please list type, dates and treatments.) (1)________________________________________________________________________ (2)________________________________________________________________________ (3)________________________________________________________________________ (4)________________________________________________________________________ (5)________________________________________________________________________ * Did you have either of these childhood illnesses? Other childhood diseases:____________________________________________________________________________________
Vaccinations
*
* MMR – Measles, Mumps and Rubella (German Measles):
Social History
* How many caffeinated beverages (coffee, tea, soda) do you drink every day?_____
Yes How many/day?_____ How many years?______ * Do you use marijuana, cocaine, or any other similar drug? Yes (describe___________________________________) Yes (describe___________________________________________________________________) * Are you aware of any radiation exposures other than X-rays? Yes (describe_________________________________) Physician Notes (for office use only)______________________________________________________________________
_____________________________________________________________________________________________________
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Surgical History
* Have you had any surgeries?
Yes (List all surgeries in chronologic order.) (1)______________________________________________ (2)______________________________________________ (3)______________________________________________ (4)______________________________________________ (5)______________________________________________ (6)______________________________________________ (7)______________________________________________ Yes (describe__________________________________________________)
Physical Symptoms
General:
Head, Eyes, Ears, Nose and Throat:
Respiratory:

Endocrine/Hormonal:
Breasts: Neurological
Problems:

Gastrointestinal:
Genito-Urinary:
Skin/Extremities:

Musculoskeletal: Hematologic:
Cardiovascular:
Blood transfusions (dates/reasons________________) antibiotics before dental procedures?) Y N Mental Health Problems:
Physician Notes (for office use only) _____________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________

Family History
What is your ancestry?
Disorders in Your Family
Would you like to be screened for:
Other (Specify__________________________________________
PRIOR INFERTILITY TESTING AND TREATMENT
* Have you had prior infertility testing or treatment elsewhere?

Prior Tests (check all that apply):
Basal body temperature chart (date_____/results_____________________________________) Thyroid test (date_____/results____________________________) Ovulation test kit (date_____/results__________________) Day 3 blood test for FSH level (date_____/results______________) Hysterosalpingogram (HSG) (date_____/results_________) Laparoscopy surgery (date_____/results_____________________) Hysteroscopy surgery (date_____/results______________) Progesterone blood test (date_____/results___________________) Prolactin blood test (date_____/results________________)
Prior Treatment (check all that apply):
Dates (mo/yr) (mo/yr)
__Pregnant__Delivered__Ectopic__ Miscarriage __ Not Pregnant Clomiphene citrate with timed intercourse: __Pregnant__Delivered__Ectopic__ Miscarriage __ Not Pregnant __Pregnant__Delivered__Ectopic__ Miscarriage __ Not Pregnant Daily fertility drug injections with insemination?: __Pregnant__Delivered__Ectopic__ Miscarriage __ Not Pregnant Completed in vitro fertilization cycle(s): 1. # eggs___ # embryos transferred__ # frozen___ __Pregnant__Delivered__Ectopic__ Miscarriage __ Not Pregnant 2. # eggs___ # embryos transferred__ # frozen___ __Pregnant__Delivered__Ectopic__ Miscarriage __ Not Pregnant 3. # eggs___ # embryos transferred__ # frozen___ __Pregnant__Delivered__Ectopic__ Miscarriage __ Not Pregnant 4. # eggs___ # embryos transferred__ # frozen___ __Pregnant__Delivered__Ectopic__ Miscarriage __ Not Pregnant __Pregnant__Delivered__Ectopic__ Miscarriage __ Not Pregnant __Pregnant__Delivered__Ectopic__ Miscarriage __ Not Pregnant __Pregnant__Delivered__Ectopic__ Miscarriage __ Not Pregnant __Pregnant__Delivered__Ectopic__ Miscarriage __ Not Pregnant Canceled in vitro fertilization attempt(s): ________________________________________________________________________________________________
* Additional Information/Complications: ____________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
EMOTIONAL STATUS
On a scale of 1-10 (10 being the worst), estimate the level of stress you feel due to infertility and other pressures. _________ Yes – For how long? _________________ How often? ________________________ List any antidepressant/antianxiety medications you are currently taking. __________________________________________ Describe any emotional, marital or sexual problems caused by your infertility. _______________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________
P ATIENT’S SIGNATURE________________________________________________________ DATE ________________________

I confirm that I have reviewed the information above.

PHYSICIAN’S SIGNATURE ______________________________________________________ DATE _______________________

Complete with your male partner, if applicable.
* Have you been evaluated by a urologist?
* Have you previously conceived with another woman? * Do you have difficulty with erections? * Do you have retrograde ejaculation of sperm into the bladder? * Have you had any of the following sexually transmitted diseases or pelvic infections? * Have you had a history of undescended testicles? * Do you have scrotal or testicular pain? * Have you had prior injury to your testicles requiring hospitalization? *Have you been diagnosed with any of the following diseases? Other neurologic problems – Yes___ No___ High Blood Pressure – Yes___ No___ If yes, any medications?__________________________ * Have you had any fever in the last 3 months? If yes, have you had a vasectomy reversal? * Have you had surgery for varicocele repair? * Did you undergo any bladder or penis surgery as a child? * Are you exposed to prolonged heat in the workplace? * Are you exposed to any radiation or harmful chemicals in the workplace? Yes (Please list and describe reactions)______________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ List your current medications: ___________________________________________________________________________________ List any current medical problem(s)_______________________________________________________________________________ * How many caffeinated beverages do you drink per day?______ * Do you use marijuana, cocaine or any other similar drug? Yes (describe____________________________________) * Do you use herbal medicines/vitamins or health food store supplements? Yes (describe_________________________) * Are you aware of any radiation/toxic materials exposure? * Did your mother take DES during pregnancy to prevent miscarriage? * Have any of your immediate family members had difficulty conceiving a child? If yes, please describe________________________________________________________________________
Physician Notes (for office use only)
_________________________________________________________________________
_______________________________________________________________________________________________________
What is your ancestry?
Disorders in Your Family
Would you like to be screened for:
Other (Specify__________________________________________
SPOUSE/MALE PARTNER’S SIGNATURE_____________________________________________ DATE________________


I confirm that I have reviewed the information above.

PHYSICIAN’S SIGNATURE__________________________________________________________DATE_______________


Physician Notes (for office use only) _________________________________________________________________________
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MALE PATIENT HISTORY
I. IDENTIFYING INFORMATION
Date____________________________________________
Name______________________________________________ Partner’s Name____________________________________
Address______________________________________________________________________________________________
Telephone Number – Day ( )__________________________________ Evening: ( ) ____________________________
Date of Birth___________ Partner’s Date of Birth____________ Duration of Relationship _______ Duration of Infertility ______
Insurance Company __________________________________________________ Insurance ID#_______________________
II. TRAVEL/WORK AND GENERAL BACKGROUND
All present employment – title(s), location, brief description, number of years employed:
_________________________ _________________________ _________________________ _____________
_________________________ _________________________ _________________________ _____________
_________________________ _________________________ _________________________ _____________
Are you or have you ever been exposed to any of the following during employment or military service:
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 the age you began: Exercise: _________ Hrs/Week _________ Age _________ Exercise _________ Hrs/Week ________ Age ________ Do you frequently take saunas or steam baths?. Have you ever had surgery in the pelvic area? ………………………………………………………………………………………. If yes, specify date and type of surgery: ________________________________________________________________ Do you have or have you had (check all that apply): Have you ever been treated for cancer?. If yes, explain therapy:______________________________________________________________________________ Within 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: ________________________________________________________________ __________________________________________________________________________________________________ Have you had a high fever (over 102°F) during the past 3-4 months? ……………………………………………………………… 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 your physician. Specify: ______________________________________________________
__________________________________________________________________________________________________
IV.
Are you circumcised? ……………………………………………………………………………………………………………………. When you were a child, were both testes descended into the scrotum? …………………………………………………………… At what age did you begin shaving regularly or start to grow a beard? __________________________________________ How many times have you been married? ________________________________________________________________ Have you ever produced a child with another partner? ………………………………………………………………………………. If yes, how long did it take to produce a child? _____________________ When was this (dates)? ___________________ Have you ever tried to produce a child with another partner? ………………………………………………………………………. Do you have trouble getting an erection? ……………………………………………………………………………………………… Maintaining an erection? …………………….…………………………………………………………………………………………… Do you have trouble with ejaculations? ………………………………………………………………………………………………… Do you feel that some of your ejaculate is deposited in the vagina?……….……………………………………………………… Do you ever have orgasms without ejaculation during masturbation? …………………………………………….……………… Do you have any discharge from the penis? ………………………………………………………………………………………… How many times per week do you and your partner now have intercourse? _____________________________________ How many times do you have intercourse around ovulation? ________________________________________________ Have you noticed a change in your sexual drive recently? ………………………………………………………………………. 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, list who (relationship to you) and what type: ________________________________________________________ __________________________________________________________________________________________________ FERTILITY
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®, Clomid®) Other – Specify _______________________________ Have you ever had varicocele repair? ………………………………………………………………………………………………… If yes, when? _____________________________________________________________________________________ Have you ever had vasectomy reversal repair? ….…………………………………………………………………………………… If yes, when? _____________________________________________________________________________________ Have you and your partner ever tried artificial insemination? …………………………………………………………………….… Have you and your partner ever tried in vitro fertilization? …………………………………………………………………………… If yes, when and explain______________________________________________________________________________ Which of the following tests have you had performed? Check all that apply and the results, if known: When? ___________ Results: _______________________ When? ___________ Results: _______________________ When? ___________ Results: _______________________ When? ___________ Results: _______________________ When? ___________ Results: _______________________ Hormonal Tests (FSH, LH, prolactin, testosterone) When? ___________ Results: _______________________ Other – Specify ____________________________ When? ___________ Results: _______________________ Is your partner currently 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 she being treated? ___________________________________________________ __________________________________________________________________________________________________ Has she ever had children with another man? …………………………………………………………………………………………… If yes, when? _______________________________________________________________________________________ FOR PHYSICIAN USE ONLY
_________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ VIII. SURGERY _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ IX. OTHER _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ X. COURSE _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ North Florida Assisted Fertility Program
Marwan M. Shaykh, MD

Source: http://www.assistedfertility.org/forms/Infertility%20History%20Form%20new%20pts%20(2).pdf