Comprehensive Medical History Form

Date:

Who referred you to our practice?

Reason for consultation:
What are your goals or expectations for your consultation?

Female Demographic Information

Patient Partner
Name:
Date of Birth:
Occupation:
Current weight: pounds
Height: feet inches

Ethnicity:

Fertility History:

Duration of relationship: years and months
Duration of unprotected intercourse: years and months
How long have you been actively attempting pregnancy? years and months
How frequently do you and your partner have intercourse? per week / per month
Have you ever used a method to keep you from getting pregnant?
If yes, describe:
If known, what is the cause of your infertility?
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Pregnancy history (female):

Pregnancy 1st 2nd 3rd 4th
Mo/Yr of conception
How long did it take to conceive?
Infertility treatment? (Y/N)
Did your current partner sire the pregnancy?
Outcome (vaginal delivery, cesarean, ectopic, miscarriage, termination)
Live birth > 37 weeks?(Y/N)
Other pregnancy complications?
How old were you when your periods first started? years
Did you develop regular monthly periods at that time?
Do you have monthly menstrual periods now?
If yes, what is the usual number of days between the start of one period to the start of the next period? days
Dates of the 1st day of your last 2 menstrual periods: / / / / / /
How many menstrual periods do you have per year?
Do you have severe cramping or pelvic pain with your menstrual periods?
Do you have pain with intercourse?
Have you been diagnosed with endometriosis?
Have you ever had a pelvic infection?
Have you ever had any of the following sexually transmitted diseases or pelvic infections?
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Please complete the following table as accurately as possible, especially the “Physician/Clinic” column.

Test Date(s) Physician/Clinic Results/Findings
Thyroid Test (TSH)
Day 3 blood test for FSH/Estrogen
AMH
Prolactin level
Hysterosalpingogram (X-Ray of Tubes/HSG)
Sonohysterography (water ultrasound)
Hysteroscopy
Genetic Testing
Endometrial receptivity testing

Health care maintenance:

When was your last pap smear (month/year)? /
When was your last abnormal pap smear (month/year)? /
Do you perform self breast exams?
Have you ever had a mammogram?
When was your last mammogram? month year

Medications/Supplements:

Are you allergic to any medications?

Are you currently taking any medications or supplements?

If yes please list below:

Medication/Supplement Start Date Dose
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Surgical History:

Please list any surgeries you have had in chronological order:

Year Reason and Type of Surgery

Social History:

How many caffeinated beverages (coffee, soda, tea) do you drink per day?
On average how much water are you consuming daily?
Do you exercise regularly?
If yes, describe:
Do you smoke cigarettes or have you ever used tobacco products?
Do you drink alcohol?
Have you ever used illicit drugs?
Are you allergic to any foods?
If yes, describe:
Have you had significant weight change in the last year?

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:
Do you see a counselor?
List any anti-depressant/anti-anxiety medication you are currently taking:
Has your infertility produced marital or sexual dysfunction?

Family History:

Have any of these illnesses occurred in your family:

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Immunization History:

Chickenpox (Varicella):
dates()
MMR-Measles, Mumps, Rubella (German Measles):
dates()
Tetanus (Tdap):
dates()
Hepatitis B:
dates()
Polio:
dates()
Influenza:
dates()

Prior Infertility Treatment:

Treatment # of Cycles Dates:From (Mo/Yr) / To (Mo/Yr) Outcome

In Vitro Fertilization Treatment History

Treatment Cycle 1 Cycle 2 Cycle 3 Cycle 4
Cycle date
IVF center/physician
Maximum gonadotropin dose (Follistim, Gonal-F, Menopur)
# Eggs retrieved
Was ICSI performed? (Y/N)
# Eggs fertilized
#Eggs/embryos frozen
Was genetic testing performed on the embryos?
Did an embryo transfer take place in a fresh or frozen cycle?
How many embryos transferred?
Embryo age (day 2, 3, 5)
Outcome
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Male History:

Male: pregnancies from previous marriage(s) or partner(s):

Pregnancy 1st 2nd 3rd 4th
Mo/Yr of conception
How long did it take to conceive?
Gender
Outcome
Have you been circumcised?
            If no, does your foreskin fully retract?
Have you ever been evaluated by a urologist?
Do you have difficulty with erections?
Do you have retrograde ejaculation of sperm into the bladder?
Have you ever had any of the following sexually transmitted diseases or pelvic infections?
Do you have a history of undescended testicles?
Do you have scrotal or testicular pain?
Have you had prior injury to your testicles requiring hospitalization?
Have you had a high fever in the last 3 months?
Have you had a vasectomy?
Have you had surgery for varicocele repair?
Have you had hernia surgery?
Did you undergo any bladder or penis surgery as a child?
Are you exposed to any radiation or harmful chemicals in the workplace?
Have you had chemotherapy for cancer?
Have you ever used testosterone, androgel or androgenic hormones?
2 5 0 0 H o s p i t a l D r i v e , B u i l d i n g 7 , M o u n t a i n V i e w , C A 9 4 0 4 0650-325-N O V A ( 6 6 8 2 ) n o v a i v f . c o m

Please complete the following table as accurately as possible, especially the “Physician/Clinic” column

Test Date(s) Physician/Clinic Results
Semen Analysis
Chromosomes (karyotype)
Genetic Testing

Medications/Supplements:

Are you allergic to any medications?

Are you currently taking any medications or supplements?

If yes please list below:

Medication/Supplement Start Date Dose
2 5 0 0 H o s p i t a l D r i v e , B u i l d i n g 7 , M o u n t a i n V i e w , C A 9 4 0 4 0650-325-N O V A ( 6 6 8 2 ) n o v a i v f . c o m