Albrechtwomenscare.com

FEMALE MEDICAL AND FERTILITY HISTORY
Date of Appointment: ________ Last Name: ______________ First Name: ____________ DOB: ________ How did you hear about our office? _____________________________________________________ What is the reason for your appointment today? ___________________________________________ What was the first day of your last menstrual flow? __________ Your age of your first menstrual flow: ______________ What is the length of your menstrual cycle? (Days between the first day of one period to the next): _________________ How many days does the flow last? _______ Do you have spotting or bleeding between periods? What is the number of pads or tampons used in 24 hours on heavy days? Pads ____ Tampons ____ Do you use tampons and pads together? Yes Do you use any medications for menstrual cramps? medications below: _________________________________________________________________________ _________________________________________________________________________________________ Do you take any prescription medications? If yes list the medication the reason and how often it is taken. Do you take any over-the-counter medications? If yes, list the medication the reason and how often it is taken. Allergies And Adverse Reactions
If you have had an adverse reaction to medication, chemicals, insect bites, insecticides, foods, etc., please list with an explanation of your reaction and the severity: Pregnancy History
How many times have you been pregnant (include miscarriages & abortions)? # term deliveries _____ # of preterm deliveries _____ # of miscarriages _____ # of ectopic pregnancies ____ Please complete the following for each pregnancy:

* Vaginal delivery (V), C-Section (CS), Miscarriage (M), Abortion (A), Ectopic Pregnancy (EP)
Were there any complications during or after your pregnancies?
Please check if you have ever had:
Uterus removed
If yes, please list: ______________________ What contraception have you used in the past? Please check all that apply. Date of your last mammogram ________ Was it normal? How often do you examine your breasts? _______ abnormality? _____________________________ What is the frequency of your sexual activity? _______/week Do you have pain with sexual intercourse? Do you or your partner use lubricants when engaged in sexual activity? Have you ever been abused sexually, physically or emotionally? Surgical History
Please list any type of surgery you have had: Medical History (Please check all that apply)
Social History
What is your occupation? _______________________ What is your ethnic heritage? ________________________
(German, Italian, African-American, Ashkenazi Jewish, etc.) What do you do for exercise? ____________________ How many days/week? _____ How many minutes? ____ Do you smoke? How many years did you or have you smoked? ______ How much alcohol do you drink? __________ per day ____ per week _____ per month If yes, which ones? ____________________ How much caffeine do you drink per day? Coffee ________ Tea ________ Soda ________ Do you follow a special diet? If yes, what kind? ____________________________ Do you or have you had an eating disorder? If yes, what kind? _____________________ If yes, what kind and how much? ____________ Do you take vitamins or other supplements? Y If yes, what kind and how much? ____________ ___________________________________________________________________________________________ What is your religious affiliation? _____________ Do you observe religious traditions? Y If yes which ones? ___________________________________________________________________________ Have you ever received a blood transfusion? Y Have you been turned down as a blood donor? Y What is your blood type? ____ Height _______ Have you traveled to a foreign country within the last year? Y __________________________________________________________________________________________ Are you immune to rubella (German measles)? Y Have you had the Chicken Pox or the vaccine series? Y Family Cancer History
Have you had any relatives with any form of cancer? type of cancer: _________________________________________________________________________________________________ _________________________________________________________________________________________________ Family Tree
Please list the names and ages of your immediate relatives. Also, please list any health problems that your relatives may have/had. If deceased, please indicate age at death, cause of death and any other health problems. If adopted please check the box to the right and skip to the next section. Mother’s name: _________________ Present age? _____ Age at death? ______ Health problems and/or cause of death: ________________________________________________________________________________________ Maternal Grandmother’s name: _________________ Present age? _____ problems and/or cause of death: _______________________________________________________________________________________________ Maternal Grandfather’s name: _________________ Present age? _____ problems and/or cause of death: _______________________________________________________________________________________________ Paternal Grandmother’s name: _________________ Present age? _____ problems and/or cause of death: _______________________________________________________________________________________________ Paternal Grandfather’s name: _________________ Present age? _____ problems and/or cause of death: _______________________________________________________________________________________________ Please list all of your siblings and children: _________________ ___________ _________ _________________ ___________ _________ _________________ ___________ _________ _________________ ___________ _________ _________________ ___________ _________ _________________ ___________ _________ _________________ ___________ _________ _________________ ___________ _________ _________________ ___________ _________
Please give details of any family history you think may be relevant to your situation: ______________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Fertility History and Therapy
These questions are specific to your fertility evaluation. If unsure of an answer, please leave blank.
How long have you been with your current partner? _________
How long have you been having unprotected sexual intercourse? ___________ How long have you been trying to conceive? _____________ Have you attempted to conceive a pregnancy with a prior If yes, were you successful? ____________________ Have you had ultrasounds to look for ovulation? Y Have you had intrauterine inseminations? If applicable, please check all of the following medications that you have taken in the past in an attempt to conceive: Clomiphene Citrate- How many cycles? ____ Letrazole (Femara)- How many cycles? ____ hMG (Repronex, Follistim, Gonal-F, Bravelle, Menopur) How many cycles? hCG (Profasi, Pregnyl, Novaral, Ovidrel) Estrogens (Premarin, Estrace, Estratest, Ogen) Bromocriptine (Parlodel, Dostinex) Danazol (Danocrine) Antibiotics Progesterone suppositories/oral progesterone injection/vaginal progesterone Prednisone GnRH agonists(Lupron, Ganerelix, Cetritide) Other Never utilized fertility medications Have you had any of the following tests/procedures performed? (check all that apply) AMH (Antimullerian hormone) Sonohysterogram (Saline ultrasound) Day 3 FSH and Estradiol Chromosomal analysis Gynecologic Surgery (Laparoscopy, myomectomy, etc.) Findings? ________________________ Ovulation predictor kits IVF (In vitro fertilization) Number of IVF cycles? _____ How many eggs obtained? ___________ How many fertilized? ______ Number of embryos transferred? _________ Embryos Frozen ______ Have any pregnancies resulted from any fertility treatments? Y If yes, which treatment and what was the outcome? _______________________________________________

Source: http://albrechtwomenscare.com/wp-content/uploads/2011/02/Female-and-Fertility-History-Form1.pdf