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Microsoft word - eivf female form.doc

FEMALE INFORMATION
Name: _____________________________________________ Birth date: ____________________________ Age: ________ Occupation: _________________________________________ Term births: ________________________________ How long have you been trying to achieve a pregnancy? ________ months of unprotected intercourse How long have you been trying to achieve a pregnancy with current partner? ________ months PREGNANCY INFORMATION
Months to
Difficulty
Fertility Treatment?
Delivery Type
Partner?
Conception
Conceiving?
_________________________ ‰ Miscarriage _________________________ ‰ Miscarriage _________________________ ‰ Miscarriage _________________________ ‰ Miscarriage ‰ Please check here, if you have had more than four pregnancies. MENSTRUAL CYCLE HISTORY
(Answer these questions about your menstrual (bleeding) pattern).
At what age did you begin having periods? ________ years old
When was the date of your last menstrual period? ________ mm/dd/yyyy
What is the average length of time your period lasts? ________ days of flow
What is the average length of time from the start of one period until the start of the next? ________ days
Within the last year, have your periods usually come (without medication) every 26-32 days? ‰ Yes ‰ No
If no, have your periods always been irregular? ‰ Yes ‰ No Do you ever have bleeding in between periods? ‰ Yes ‰ No Do you currently need to take medication in order to get a period? ‰ Yes ‰ No ‰ Premarin ‰ Estrace ‰ Birth Control Pills ‰ Progesterone (if Progesterone, please specify type, below:) ‰ Provera ‰ Cycrin ‰ Aygestin ‰ Crinone ‰ Prometrium ‰ Other: ________________________________ Do you have pelvic pain with your periods? ‰ Yes ‰ No If yes, please indicate the level of pain that you usually experience: Do you often experience pelvic pain in between periods? ‰ Yes ‰ No If yes, do you take medication for pain? ‰ Yes ‰ No If yes, which one(s)? ____________________________________________________ If yes, does the medication relieve pain? ‰ Yes ‰ No Female Information
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Have you ever used home ovulation predictor kits? ‰ Yes ‰ No If yes, what evidence for ovulation did you see? (‰ A positive test ‰ Color change ‰ Other: _____________________ If yes, what day or range of days does it turn positive on? ________ (Example: Day 14-15) Have you ever used any contraceptives? ‰ Yes ‰ No ‰ Intrauterine device (IUD) ‰ Tubal Ligation (Tubes tied) Are you currently using any contraceptives? ‰ Yes ‰ No ‰ Intrauterine device (IUD) ‰ Tubal Ligation (Tubes tied) GYNECOLOGIC HISTORY
If not, when was the last pap done? ________________ mm/dd/yyyy Have you ever had an abnormal pap? ‰ Yes ‰ No If yes, what was the abnormality? ____________________________ If not, when the last mammogram was done? ________________ mm/dd/yyyy Do you have any breast discharge? ‰ Yes ‰ No Do you currently have acne? ‰ Yes ‰ No Do you have unwanted (facial, arm, chest, or other male pattern) hair growth that requires cosmetic removal? ‰ Yes ‰ No ‰ Heterosexual ‰ Homosexual ‰ Never been sexually active What is the number of sexual partners you have had in the past 2 years? _______ Do you have a history of sexual abuse? ‰ Yes ‰ No If yes, have you received counseling ‰ Yes ‰ No Would you like us to make a referral for counseling? ‰ Yes ‰ No Do you often have pain with intercourse? ‰ Yes ‰ No How frequently do you have intercourse? ___________per week Have you ever had any of the following procedures performed? Procedure
Date (Mo/Yr)
Findings
Procedure
Date (Mo/Yr)
Have you had any exposure to or have been treated for any sexually transmitted disease or pelvic infection? ‰ Yes ‰ No MEDICAL HISTORY
Do you have long-standing medical conditions? ‰ Yes ‰ No Medical Condition
Comments/Findings
‰ Please check here, if you have more than five medical conditions. Female Information
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Have you ever needed or used thyroid medication? ‰ Yes ‰ No ‰ Synthroid ‰ Levoxyl ‰ Other: _________________ Are you currently taking any medication? ‰ Yes ‰ No Medications
Reason / Comments
‰ Please check here, if you are taking more than five medications. Have you had the following vaccinations? ‰ Yes ‰ No Vaccination
Date (Mo/Yr)
Vaccination
Date (Mo/Yr)
Are you allergic to or have had any adverse reaction to any drugs? ‰ Yes ‰ No Medications
Reaction / Comments
‰ Please check here, if you are allergic to or have adverse reaction to more than five medications. Have you had any surgeries? ‰ Yes ‰ No Indication
Findings
Complications
‰ Please check here, if you have had more than five surgeries. Have you ever been diagnosed with HIV? ‰ Yes ‰ No ENVIRONMENTAL FACTORS
If yes, how much? ________ (# of cigarettes/day) If yes, how much? ________ (# of cigarettes/day) when did you quit? ________ (Mo/Yr) If yes, how would you describe your drinking habits? ‰ Alcoholic . _______ drinks / ________ (how often?) Female Information
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Do you have alcohol dependence? ‰ Yes ‰ No Do you consume caffeinated beverages? ‰ Yes ‰ No If yes, how much? ‰ 1-2 per day ‰ 3-4 per day ‰ More than 5 per day Do you currently use "recreational" drugs? ‰ Yes ‰ No If yes, what? ______________________________________ Do you use herbal remedies or medications? ‰ Yes ‰ No Do you engage in long distance running or similar strenuous exercise? ‰ Yes ‰ No If yes, how much (often) per week? ________ GENETIC / FAMILY HISTORY
Do you or anyone in your family have any of the following medical conditions? ‰ Yes ‰ No Medical Condition
Mental Retardation - Chromosomal Testing Mental Retardation - Testing for Fragile X Mutation Chromosome Disorder (e.g. Down’s Syndrome) Do you have a birth defect or familial disorder not listed above? ‰ Yes ‰ No If yes, Please describe? _________________ What is your mother’s ancestry? _____________________________________ What is your father’s ancestry? _____________________________________ Have you or your significant other in this or any previous relationship had a stillborn child or more than two first trimester miscarriages? ‰ Yes ‰ No
Eastern European /Jewish Acestry

Have you had Tay Sach’s screening tests? ‰ Yes ‰ No If yes, when? _______ (Mo/Yr). What were the findings? ‰ Normal ‰ Abnormal: _________________ Have you had a Canavan Screening Test? ‰ Yes ‰ No If yes, when? _______ (Mo/Yr). What were the findings? ‰ Normal ‰ Abnormal: _________________ Female Information
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Have you had Bloom Screening Test? ‰ Yes ‰ No If yes, when? _______ (Mo/Yr). What were the findings? ‰ Normal ‰ Abnormal: _________________ Have you had Gaucher Screening Test? ‰ Yes ‰ No If yes, when? _______ (Mo/Yr). What were the findings? ‰ Normal ‰ Abnormal: _________________ Have you had Fanconi Anemia Screening Test? ‰ Yes ‰ No If yes, when? _______ (Mo/Yr). What were the findings? ‰ Normal ‰ Abnormal: _________________ Have you had Neimman-Pick Screening Test? ‰ Yes ‰ No If yes, when? _______ (Mo/Yr). What were the findings? ‰ Normal ‰ Abnormal: _________________ African Ancestry
Have you had Sickle cell screening tests? ‰ Yes ‰ No If yes, when? _______ (Mo/Yr). What were the findings? ‰ Normal ‰ Abnormal: _________________ European Ancestry or Family member with cystic fibrosis
Have you been tested for Cystic fibrosis? ‰ Yes ‰ No If yes, when? _______ (Mo/Yr). What were the findings? ‰ Normal ‰ Abnormal: _________________ Italian, Greek, Mediterranean or Southeast Asian Ancestry
Have you had screening for inherited forms of anemia such as thalassemia? ‰ Yes ‰ No If yes, when? _______ (Mo/Yr). What were the findings? ‰ Normal ‰ Abnormal: _________________ INFERTILITY TESTS
Have you had any of the following fertility tests in the past? ‰ Ultrasound of the uterus and/or ovaries when NOT pregnant?
If yes, when? _______ (Mo/Yr). What were the findings? ‰ Normal ‰ Abnormal: _________________ ‰ Hysterosalpingogram (HSG)? An x-ray test of the uterus and tubes during which dye is injected into the uterus to “see” it
If yes, what were the findings? ‰ Normal uterus ‰ Abnormal uterus ‰ Both tubes open ‰ One tube blocked ‰ Both tubes blocked ‰ Hysterosonogram (also called sonohysterogram)? An ultrasound test in which saline (salt water is injected and an ultrasound is used to “see” the uterus.
If yes, what were the findings? ‰ Normal uterine cavity ‰ Abnormal uterine cavity: _________________ ‰ Laparoscopy? A telescope is placed through the belly button to see inside your abdomen
Date (Mo/Yr)
Indication
Findings
Complications
‰ Please check here, if you have had more than three Laparoscopy tests. Hysteroscopy? A telescope is placed through the vagina into the uterus in order to see the inside of the uterus.
Date (Mo/Yr)
Indication
Findings
Complications
‰ Please check here, if you have had more than three Hysteroscopy tests.
Other tests to specifical y look at possible causes of infertility, miscarriage, or problems with menstrual cycle?
Date (Mo/Yr)
Female Information
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Date (Mo/Yr)
Chromosome Analysis (Karyotype) - Female Chromosome Analysis (Karyotype) - Male Partner PAST FERTILITY TREATMENTS
Have you ever had any Clomiphene citrate (Clomid, Serophene) cycle? ‰ Yes ‰ No
If yes, please list the last four (most recent) information below: ‰ OHSS ‰ Birth Defect/ Abortion ‰ Miscarriage <20 wks ‰ OHSS ‰ Birth Defect/ Abortion ‰ Miscarriage <20 wks ‰ OHSS ‰ Birth Defect/ Abortion ‰ Miscarriage <20 wks ‰ OHSS ‰ Birth Defect/ Abortion ‰ Miscarriage <20 wks ‰ Please check here, if you have had more than four Clomiphene cycles. Female Information
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Have you ever had any Gonadotropins (Pergonal, Metrodin, Repronex, Humegon, Fertinex, Gonal-F, Follistim, Cetrotide, Antagon, Lupron) cycle? ‰ Yes ‰ No
If yes, please list the last three (most recent) Gonadotropin cycles nformation below: ‰ OHSS ‰ Birth Defect/ Abortion ‰ Miscarriage <20 wks ‰ OHSS ‰ Birth Defect/ Abortion ‰ Miscarriage <20 wks ‰ OHSS ‰ Birth Defect/ Abortion ‰ Miscarriage <20 wks ‰ OHSS ‰ Birth Defect/ Abortion ‰ Miscarriage <20 wks ‰ Please check here, if you have had more than four Gonadotropins cycles. Have you ever had any In-Vitro Fertilization (IVF) cycle? ‰ Yes ‰ No
If yes, please list the last three (most recent) IVF cycles information below:
‰ OHSS ‰ Birth Defect/ Abortion ‰ Miscarriage <20 wks ‰ OHSS ‰ Birth Defect/ Abortion ‰ Miscarriage <20 wks ‰ OHSS ‰ Birth Defect/ Abortion ‰ Miscarriage <20 wks ‰ OHSS ‰ Birth Defect/ Abortion ‰ Miscarriage <20 wks ‰ Please check here, if you have had more than four Gonadotropins cycles. Female Information
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Have you ever had any Frozen Embryo cycle? ‰ Yes ‰ No
If yes, please list the last three (most recent) Frozen Embryo cycles information below: ‰ Birth Defect/ Abortion ‰ Miscarriage <20 wks _ ‰ Birth Defect/ Abortion ‰ Miscarriage <20 wks _ ‰ Birth Defect/ Abortion ‰ Miscarriage <20 wks _ ‰ Birth Defect/ Abortion ‰ Miscarriage <20 wks _ ‰ Please check here, if you have had more than four Frozen Embryo cycles. Have you ever had any Gestational Surrogacy or Donor Egg Cycles? ‰ Yes ‰ No
If yes, what was the indication: ______________________________ Have you ever been an egg donor? ‰ Yes ‰ No Powered by eIVF, a PracticeHwy.com product

Source: http://ivf-success.com/resources/eIVF-FemaleQuestionnaireForm.pdf

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