FERTILITY QUESTIONNAIRE

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JAN RYDFORS MD FACOG, RUBI KHILNANI MD FACOG

FERTILITY QUESTIONNAIRE
Please complete and bring this questionnaire before your first prenatal visit and bring it with you. We will review it with you.

Name : __________________ Age: ____ Date of Birth: _____ Tel. #-Day: _____- _____- ____ Evening: ___--_____-_______ Partner's Name: ___________________ Partner's date of birth:____________

GYNECOLOGICAL HISTORY How old were you when you had you first period ______ How frequently do your periods come? Every ___days How long do your periods last? _____days. When did your last period start? ______ Do you experience cramping with your periods? Yes No

If yes, when during your cycles do you have pain (check all that apply) : Before During After Mild Moderate Yes Severe

How would you describe the cramps?

Do you take pain medication for the cramps?

No If yes, specify

medication_____________________________________ Do you bleed or spot between periods? Yes No

If yes, please describe:______________________________________________ Have you ever had an abnormal Pap smear result? ________ If yes, what therapy was required : Cone biopsy LEEP Cryotherapy(freezing of cervix) Laser therapy

Other: _____

Have you ever had any of the following infections involving any part of the reproductive tract (vagina,cervix.uterus,ovaries)? Check all that apply Chlamydia Trichomonas Gonorrhea Herpes Genital warts

What treatment did you receive? ________________Year:____ Do you have pain with intercourse? never sometimes frequently always

If yes, does the pain remain in your lower abdomen after intercourse if over ? Yes No if yes, for how many minutes? : ______

How frequently do you and your partner have intercourse? _____per week/Month (circle)

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FERTILITY QUESTIONNAIRE

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How frequently do you and your partner have intercourse around ovulation? ____times per month Do you usually use lubrication during intercourse? If yes, please specify: _____________ Have you experienced any difficulties with intercourse that may be contributing to infertility? Yes No If yes, please explain: ____________________________________________ Yes No Yes No

Have you ever used contraception in the past? if yes, please check all that apply: Contraceptive pills Withdrawal Condoms IUD

Foam/Sponge

Rhythm

Other ______________

FERTILITY EVALUATION How long have you and your partner been attempting to achieve pregnancy? _____ Have you been using temperature charts? If yes, for how long?____ ____ months Have you been using urine ovulation predictors Yes No if yes, what kind and for how long? _________________________________ Yes No Yes No

Have you ever tried to achieve a pregnancy with a different partner Have you ever conceived with a different partner? Yes No Yes

Has your male partner ever gotten someone else pregnant? Have you been treated for infertility previously Yes

No

No If Yes, where/when: _____________________________________________

What was the cause of infertility? _______________________________________________ Which of the following tests have allready been performed? Infection test (mycoplasma,Chlamydia) Hysteroscope Hormonal tests Antichlamydia Antibody Ultrasound Sonohysterogram Postcoital test Endometrial biopsy

Hysterosalpingogram (HSG)

Antisperm antibody

Laparoscopy

Have you ever taken any of the medications listed below? Clomiphene (Clomid,Serophene) Injectable gonadotropins

(Pergonal,Repronex,Humagon,Fertinex,Gonal-F, Follistim) HCG (Profasi, Pregnyl) GnRH agonist (Lupron,Synarel,Zoladex) GnRH Antagonist (Antagon) Estrogens

steroids (prednisone, dexamethasone) Bromocriptine (Parlodel, Dostinex) Glucophage (Metformin) Progesterone

Heparin

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FERTILITY QUESTIONNAIRE

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Baby aspirin

Danazol Yes No

Have you ever had Intrauterine inseminations (IUI)? if so, for how many cycles? _____________cycles If yes, specimen was provided by : Check all that apply) Have you ever attempted in vitro fertilization? Yes

Partner

Donor

No if yes, please specify below :

_______________________________________________________________________________ OBSTETRICAL HISTORY Have you ever been pregnant (including elective terminations, miscarriages, births? Yes No

PAST MEDICAL HISTORY Do you have or have you ever had any of the following (check all that apply): Ovarian cysts Anemia Endometriosis hair loss Seizures hot flashes Gallbladder disease high blood pressure vision problems Arthritis mumps

Heat/cold intolerance

Hirsutism (excess hair growth) Cystic Fibrosis Colitis Acne Diabetes

Breast (Nipple discharge) Kidney /Liver problems German Measles

chronic headaches

Regular Measles Immunizations: Mumps

Neurological problems Tetanus Hepatitis B Hepatitis B or C

Autoimmune disease (e.g. Lupus) German Measles Polio

Chicken Pox

PAST SURGICAL HISTORY Have you ever had any surgeries in the past ? Yes No If yes, please indicate date, type, findings of surgery:

_____________________________________________________________________________ FAMILY HISTORY Have any of these problems occurred in your family? Check all that apply and indicate relationship to you: High blood pressure _______________ Infertility ________________ Heart disease _______________ diabetes _______________ Ovarian cancer ___________

DES exposure in utero/early menopause ___________ colon/breast CA ___________

Thyroid disease __________

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FERTILITY QUESTIONNAIRE

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REVIEW OF SYSTEMS Have you noted any significant: Heat/Cold intolerance recently? Yes No if yes, please explain:

_____________________________________________ Unusual hair distribution changes or breast nipple discharge ? if yes, please explain: ______________________ Significant weight change in the last year? If so, please describe how many lbs and over what time: ________________________ HABITS Do you smoke? Yes No if yes, how many packs per day? ________ Yes No

Do you take hot baths? ___ Do you drink alcohol Do you smoke marijuana Do you exercise regularly? Yes Yes Yes No if yes, how many alcoholic beverages per week: __________ No if yes, how much per week: ________ No if yes, please indicate type of exercise

and estimate hrs per week spent _________________________________ ________________________________ _______________________________ ALLERGIES to medication Are you allergic to any medication? Yes No

if yes, please indicate name of medication and type of reaction Medication Reaction __________ ________ __________ ________ MEDICATIONS: Are you currently taking any prescription medications Medications Reason ___________ __________ ___________ __________ Do any of you use herbal medications? Yes No Yes No

if yes, types of medications used: ________

SECTION FOR MALE PARTNER

Which of the following test have already been performed?

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FERTILITY QUESTIONNAIRE

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Semen analysis

Chromosome test

Hamster egg penetration test

test (FSH,LH,Prolactin,Testosterone) Ultrasound of testis Antisperm antibody test myco/Ureaplasma culture q Testicular biopsy

Have you ever had any of the following procedures done? (check all that apply)_ Varicocele repair testicular biopsy hernia repair prostate surgery testicular torsion repair

vasectomy reversal

other (please specify): ______________________ Yes No If yes, please describe:

Have you ever had any significant testicular injury?

__________________________________________________________________________________ Have you ever taken any of the medications listed below?: Clomiphene (Clomid,Serophene) Proxeed Testosterone Viagra

GnRH agonist (Lupron,Synarel,Zoladex Other (please list): _________

Bromocriptine (Parlodel, Dostinex)

Do you have or have you ever had any of the following (check all that apply): Cystic Fibrosis Delay of puberty Anemia Arthritis Seizures Cancer Neurological problems

Autoimmune disease high blood pressure chronic headaches Regular Measles Immunizations: Tetanus Hepatitis B

Heat/cold intolerance vision problems

Testicular tumor Colitis Cystic Fibrosis q Diabetes

Kidney /Liver problems German Measles mumps

Mumps with testes involved

German Measles

Polio

Mumps

Chicken Pox

Hepatitis B or C

PAST SURGICAL HISTORY

If yes, please indicate date, type, findings of surgery:

____________________________________________________________________________ FAMILY HISTORY Have any of these problems occurred in your family? Check all that apply and indicate relationship to you: High blood pressure _______________ Infertility ________________ Heart disease _____________ diabetes ____________ Ovarian cancer _________

Prostate CA ___________ colon/breast CA __________

Other ___________

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FERTILITY QUESTIONNAIRE

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REVIEW OF SYSTEMS Have you noted any significant: Heat/Cold intolerance recently? Yes No if yes, please explain:

_____________________________________________ Unusual hair distribution changes? Yes No if yes, please explain:

_____________________________________________ Significant weight change in the last year? If so, please describe how many lbs and over what time: ______________________

HABITS Do you smoke? Yes No if yes, how many packs per day? ________ Yes No No if yes, how many alcoholic beverages per week: __________ Yes Yes No if yes, how much per week: ________ No if yes, how much per week: ________ Yes No if yes, please indicate type of exercise and

Do you drink alcohol

Do you smoke marijuana Do you take hot baths

Do you exercise regularly? estimate hrs per week spent

___________________________________________ __________________________________________ __________________________________________

ALLERGIES TO MEDICATIONS Are you allergic to any medication? Yes No

if yes, please indicate name of medication and type of reaction Medication Reaction __________ ________ __________ ________

MEDICATIONS: Are you currently taking any prescription medications Yes No Medications: ___________ Reason: _____________ Yes No if yes, types of medications used: ________

Do any of you use herbal medications?

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