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PATIENT HISTORY - FERTILITY Name ___________________________________________________________________________________ Date: __________________ Age: ____________ Medical Physician: _______________________________ Sex: M / F Ht: ____________ Wt: ____________ Chiropractic Physician: _______________________________ How long have you been trying to conceive? _____________________________________________________________ List all therapies you are currently doing or intend to do: ________________________________________________ __________________________________________________________________________________________________ List all therapies tried thus far: _______________________________________________________________________ ___________________________________________________________________________________________________ Questions / comments ________________________________________________________________________________ Social History: Marital status Married Widow Divorced Separated Single Children & Ages:___________________________________________________________________________________ Habits: None Alcohol Coffee Soda Tobacco Drugs Appetite Light Mod Heavy None Sugar Sweetener Water Work Sleep Exercise cups/day = Light Mod Heavy glasses/day = Type of job: __________________ For how long? _________ Typical job duties: _______________________________ Stress level: low mod Typical diet: balanced high Most of day spent: fast food vegetarian sitting standing walking lifting other ________________________________________ Past Medical History: Surgeries: none yes ____________________________________________________________________________ Fractures: none yes ____________________________________________________________________________ Metal / implants in your body (rods/caging/plates/screws/defib/pacemaker) History of: head trauma stroke sprain/strain None Yes _______________________ hospitalization _____________________________________ Illness / disease: ____________________________________________________________________________________ Natural Arts Chiropractic & Acupuncture, PLLC - 2007 - All Rights Reserved © 2200 W. 49th St. Ste 106 Sioux Falls, SD 57105 PATIENT HISTORY - FERTILITY Family Medical History: Relationship Present & Past Health Problems Review of Systems: (check any that currently have or have had in the past) General Allergies Anemic Convulsions / seizures Dizziness Fatigue Headache Lymphadenopathy Loss of sleep Loss of weight Memory problems Night sweats Tremors / tics Cardiovascular Ankle swelling Arm pain Chest tightness Cold hands / feet Heart attack(s) High blood pressure Low blood pressure Murmurs / palpitations Pacemaker Rapid heartbeat EENT Asthma Cold / coughing Difficulty talking Dry throat Ear ache Ear ringing (tinnitus) Ear discharge Enlarged lymph nodes Enlarged thyroid Eye pain / sensitive eyes Hay fever Nose bleeds Poor or altered vision Sinusitis Loss or change in smell TMJ Endocrine Appetite changes Dry hair / skins Flushing Hair loss Hot flashes Hyperglycemia Hypoglycemia Hyperthyroidism Hypothyroidism Thirsty Unusual fatigue Unusual weight change Genitourinary Bed wetting Blood in urine Difficulty urinating Dribbling / loss of control Erectile dysfunction Herpes Painful intercourse Painful testicles Painful urination Prostate troubles Psychiatric Alcoholism Anger problems Anxiety Bipolar Drug addiction Sex abuse victim Suicidal thoughts Gastrointestinal Belching / gas Bloating Respiratory Bloody stools Asthma Colitis / colon troubles Chronic cough Constipation COPD Cramps Spitting up blood Diarrhea Sleep apnea Excessive bowel movements Gallbladder troubles Skin Hemorrhoids boils / rashes Jaundice / liver troubles hives / allergies Painful bowel movements bruise easily Painful abdomen dermatitis Rectal bleeding eczema Vomiting of blood psoriasis Musculoskeletal Numb/painful arms/legs Numb/painful spine Sciatica Scoliosis Disc problems Fibromyalgia Women Only Lump in breast Back pain with period Menopausal Vaginal sores Vaginal discharge Unusual menstrual flow Comments on Review of Systems: _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ Natural Arts Chiropractic & Acupuncture, PLLC - 2007 - All Rights Reserved © 2200 W. 49th St. Ste 106 Sioux Falls, SD 57105 PATIENT HISTORY - FERTILITY 15 – MENSTRUAL HISTORY At what age did your menses begin? _______________ How many days are between one period to the next? ________________ Date of the 1st day of most recent cycle? __________ Day of cycle are you on? _______ Day of cycle you typically ovulate? _______ Describe the flow: very light light medium Complications: Painful period s for ________ days heavy varies Blood color: Frequent clotting Occasional clotting Spot b/t periods Bleed/spot after intercourse for _______________ days (typically flow) black brown Pre-menstrual tension PMS purple red light red Pre-menstrual breast tenderness Pre-menstrual breast tenderness Face breaks out before or after period Irregular cycles Breast tenderness during ovulation Cannot ovulate without medication ______________________ Pre-menstrual lower back pain Cycle changes (shorter / longer) Loose bowels during period 16 – FERTILITY TREATMENT HISTORY Have you ever undergone fertility treatments? Yes No If yes, please list below; by whom, when, and what type(s): ____________________________________________________________________________________________________________ Have you had your fallopian tubes evaluated? Yes No If yes, please list below; by whom and the results: ____________________________________________________________________________________________________________ Have you ever had any tubal ligations? Yes No If yes, when? ________________________________________ Have you had any hormonal lab tests done ? Yes No If yes, what were the results? __________________________ Have you been trying to conceive with 1 man? Yes No Is he supportive of your wish to conceive? Has he ever undergone a fertility workup? Yes No If yes, what were the results? ____________________________ How long you been married or living together? Yes No Diagnoses related to infertility: 17 – PREGNANCY HISTORY Total pregnancies _______ Full term deliveries _______ Premature deliveries _______ Abortions ________ Miscarriages _______ 18 – CONTRACEPTIVE HISTORY Have you taken oral contraceptives? Yes No If yes, when, what & how long? ____________________________________ Have you ever had an IUD? Yes No If yes, when & how long? _________________________________________ Have you ever taken Depo Provera? Yes No If yes, when & how long? __________________________________________ Have you used a diaphragm Yes No If yes, when & how long? Natural Arts Chiropractic & Acupuncture, PLLC - 2007 - All Rights Reserved © 2200 W. 49th St. Ste 106 Sioux Falls, SD 57105 PATIENT HISTORY - FERTILITY 19 – GENERAL GYNECOLOGICAL HISTORY Have you ever had an abnormal pap smear? Yes No What is the date of your last pap smear? _________________ Have you ever had a cervical operation? Yes No Have you ever had a cervical conization? Yes No Have you ever had a cervical biopsy? Yes No Have you ever had uterine fibroids / polyps? Yes No Have you ever had endometriosis? Yes No Have you ever had pelvic adhesions? Yes No Have you ever had pelvic abnormalities? Yes No If yes, what where they? _______________________________ Have you ever had pelvic inflamm. disease? Yes No If yes, were you ever treated for it? Yes No What did the treatment consist of? ________________________________________________________________________________ Have you ever had a Chlamydia infection? Yes No Have you ever had a venereal disease? Yes No Do you have chronic vaginal discharge? Yes No Do you have any sores on your genitalia? Yes No Do you regularly douche? Yes No If yes, with what? ___________________________________ Do you regularly use vaginal lubricants? Yes No Please rate your typical sexual energy Do you have excessive facial hair? Yes No Do you have excessive oily skin? Yes No Have you lost excessive amounts of your hair? Yes No Do you notice discharge from you nipples? Yes No Are you currently taking steroids of any kind? Yes No Do you get yeast infections regularly? Yes No Was your mom exposed to diethylstilbestrol (DES) when she was pregnant with you? Yes No Low Norm Hi Unsure List ALL medications you have taken for gynecological conditions (other than contraceptives) ________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ If there is anything else you would like us to know, please comment here: ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ Natural Arts Chiropractic & Acupuncture, PLLC - 2007 - All Rights Reserved © 2200 W. 49th St. Ste 106 Sioux Falls, SD 57105
