Download FORM 412 - REI Intake

Reproductive Endocrine History Form
IMPORTANT:
Please complete this form prior to your visit.
This form was developed by the American Society for Reproductive
Medicine and UCSF to assist physicians and patients in obtaining a
complete infertility history. It consists of three parts:
Part I: Contact information
Part II: Your medical history
Part III: Your spouse/male partner’s medical history (if applicable)
PART I: CONTACT INFORMATION
Age
Legal First Name
Middle Initial
Date of Birth (MM/DD/YY)
/
/_
Last Name
Occupation
Social Security #
Home Street Address
City
State Zip/Postal Code
Country
Indicate which number to call or leave messages.
□ Home Telephone (
)
Are you married?
□ Yes
□ Work Telephone (
□ No
□ Cell Phone (
)
)
□ Divorced □ Other_
Age
Spouse/Male Partner’s First Name
□ Not Applicable
Date of Birth (MM/DD/YY)
/
Middle Initial
/_
Last Name
Occupation
Social Security #
Home Street Address
City
State
Zip/Postal Code
Indicate which number to call or leave messages.
□ Home Telephone (
)
Country
□ Work Telephone (
)
Who referred you?
□ Physician
Name
Address
□
□
□
Phone (
)
Phone (
)
Former Patient/Friend
Web Site
Insurance (Name of Insurance)_
Who is your Ob/Gyn?
Name
Address
Page 1
□ Cell Phone (
)
Who is your Primary Care Physician?
Name
Address
Phone (
)
_
_
PART II: FEMALE MEDICAL HISTORY AND INFORMATION
Reason for Visit:
□ No Menses □ Recurrent Pregnancy Loss □ Premature Ovarian Failure □ Menopause □ Other
What are your expectations for this visit?
What questions do want answered at this visit?
Pregnancy Summary
 Total Number of ALL Pregnancies:




□ Number of Miscarriages (less than 20 weeks):
□ Number of Elective Terminations (Abortions):
Number of Ectopic/Tubal Pregnancies:
Number of Full Term Deliveries:
Of these, how many were live births?
Number of Premature (less than 37 weeks) Deliveries:
How many were stillborn?
How many were stillborn?
Of these, how many were live births?
Any Pregnancies with Birth Defects? □ Yes - explain
Date Pregnancy
Ended or Delivered
Months to
Conception
□ No
Treatments to
Conceive
Delivery Type/D&C/
Complications









□ Regular periods
□ Heavy periods
□ Irregular periods
□ Light periods
□ Spotting before periods
□ Bleeding between periods
Current
Partner?
□Y□N
□Y□N
□Y□N
□Y□N
□Y□N
□Y□N
□ No periods
Number of days between the start of one period to the start of the next period:
days
How many days of bleeding do you have?
days
Dates of the 1st day of your last 2 menstrual periods:
/_
/
;
/_
/
Age when you had your first period:
years old
Age when you first noticed: Breast development:
years old Pubic hair:
years old Underarm hair:
years old
How many periods do you have per year?
□ No
Do you need medication to bring on a period? □ Yes - what type?
If you do not have periods, at what age did you stop having them?
years old
Do you have severe cramping or pelvic pain with your periods? □ Yes: Always Sometimes Recently In the past □ No
Contraceptive History
□ Diaphragm - dates of use
□ None □ Condoms - dates of use
□ Birth control pills - dates of use
- complications?
□ Injectable contraception (Depo-Provera®, Lunelle™, etc.) - dates of use
□ Skin patch - dates of use
- complications?
□ Tubal sterilization procedure (tubes tied) - date (month/year)_
/_


Sex
□B□G
□B□G
□B□G
□B□G
□B□G
□B□G
1.
2.
3.
4.
5.
6.
Menstrual History
 Menstrual cycle pattern (check all that apply):
Wt
□ IUD - dates of use
□ Never used birth control pills
- complications?
□ Foam or Jelly
□ Tubes untied - date (month/year)_
Did your mother take DES when she was pregnant with you? □ Yes □ No □ Don’t know
At what age did your mother go through menopause:
Sexual History
 How many times do you have intercourse per week?
times per week □ None □ Not applicable
 Have you used over-the-counter ovulation kits to time intercourse? □ Yes □ No
 Do you have pain with intercourse? □ Yes □ No
Page 2
/_

Do you use lubricants (K-Y Jelly®, etc.) during intercourse? □ Yes - what types?
□ No
Have you had any of the following sexually transmitted diseases or pelvic infections? □ Yes (check all that apply) □ No
Genital warts/HPV - date_
□ Chlamydia - date_
□ Gonorrhea - date_
□ Herpes - date_
□ Syphilis - date_
Other - date_
□ HIV/AIDS - date_
□ Hepatitis - date_
Pap Smear History
 When was your last pap smear (month and year)?
/
□ Normal
 When was your last abnormal pap smear?
□ Not applicable
□ Abnormal
Have you undergone any procedures as a result of an abnormal pap smear?
□ Yes (check all that apply) □ No
□Colposcopy
□ Cryosurgery (Freezing)
Breast Screening History
Have you ever had a mammogram? □ Yes - date_
Do you perform breast self exams? □ Yes □ No
□ Laser treatment
Result:
□ normal
□ Conization
□ LEEP procedure
□ abnormal - explain
□ No
Medical History
 Are you allergic to any medications? □ Yes □ No (Please list and describe reactions)

Are you allergic to any foods (peanuts, eggs, etc.)? □ Yes □ No (If yes, please list and describe reactions)

List any medications you are currently taking, including over-the-counter medicines.

Do you take any herbal medicines/vitamins or health food store supplements? □ Yes □ No (Please list)_

Do you have any medical problem(s)? □ Yes (Please list type, dates, and treatments.) □ No
(1)_
_
(2)_
(3)_
(4)_
(5)_
 Did you have either of these childhood illnesses? □ Chickenpox (Varicella) □ German Measles (Rubella) □ Don’t know
 Other childhood diseases:_
Surgical History
 Have you had any surgeries? □ Yes (List all surgeries in chronologic order.)
□ No
Year







Reason and Type of Surgery
(1)_
(2)_
(3)_
(4)_
(5)_
(6)_
Did you have any anesthesia problems? □ Yes (describe
) □ No
Social History



How many caffeinated beverages (coffee, tea, soda) do you drink per day?
□ None
Do you smoke cigarettes? □ Yes □ No How many/day?
How many years?
□ Quit - when?
 Do you drink alcohol? □ Yes □ No
 □ Beer - # per week
□ Wine- # per week
□ Liquor - # per week
Do you use marijuana, cocaine, or any other similar drug? □ Yes (describe
Page 3
Second-hand Exp □ Yes □ No
) □ No




Do you exercise? □ Yes □ No Regularly? □ Yes □ No
How many hours of moderate exercise per week (i.e. walking, yoga)
How many hours of vigorous per week (i.e. running)
Are you aware of any radiation exposures other than X-rays? □ Yes (describe
) □ No
Do you feel safe in your own home? □ Yes (describe
□ No
Physical Symptoms
General:
Head, Eyes, Ears, Nose, and Throat:
Respiratory:
□ Recent weight gain or loss
□ Dizziness □ Loss of sense of smell
□ Shortness of breath
□ Anorexia/Bulimia
□ Headaches □ Chronic nasal congestion
□ Asthma □ Bronchitis
□ Lack of energy
□ Blurred vision □ Ringing ears
□ Pneumonia □ Tuberculosis
□ Fever/Chills
□ Hearing loss/deafness
□ Bloody cough
□ Other
□ Other
□ Other
□ None
□ None
□ None
Endocrine/Hormonal:
Breasts:
Neurological Problems:
□ Diabetes □ Hair loss
□ Discharge (clear?
□ Thyroid gland problems
□ Lumps □ Pain □ Cancer
□ Seizures/Epilepsy
□ Rapid weight gain or loss
□ Abnormal mammogram
□ Headaches
□ Excessive hunger/thirst
□ Reduction
□ Migraine headaches
□ Temperature intolerance–
□ Augmentation/Breast implants
□ Numbness
hot flashes or feeling cold
(saline?
□ Memory loss
□ Other
□ Other
□ Other
□ None
□ None
□ None
Gastrointestinal:
Genito-Urinary:
Skin/Extremities:
□ Nausea/Vomiting □ Ulcers
□ Bladder infections
□ Unexplained rash/inflammation
□ Hepatitis □ Diarrhea
□ Kidney infections
□ Acne
□ Blood in your stools □ C o n s t i p a t i o n
□ Vaginal infections
□ Skin cancer
□ Irritable Bowel Syndrome
□ Frequent urination □ Leaking urine
□ Burn injury
□ Change in bowel habits
□ Blood in the urine
□ Moles changing in appearance
□ Colitis (ulcerative or Crohn’s)
□ Herpes
□ Excess hair growth
□ Other
□ Other
□ Other
□ None
□ None
□ None
Musculoskeletal:
Hematologic:
Cardiovascular:
□ Unusual muscle weakness
□ Blood clotting disorder/Blood clot
□ Palpitations/Skipped beats
□ Decreased energy/stamina
□ Sickle Cell Anemia □ Thrombophlebitis
□ Chest pain □ Heart attack
□ Rheumatoid arthritis
□ Easy bruising
□ Stroke □ Murmurs
□ Lupus Erythematosus
□ Swollen glands/lymph nodes
□ Myasthenia gravis
□ Blood transfusions (dates/reasons_
□ Other
□ Other
□ Mitral valve prolapse (Need antibiotics
□ None
□ None
before dental procedures?) Yes_
silicone?
bloody?
milky?
□ Weakness/Loss of balance
)
)
Page 4
□ High blood pressure
)
□ Rheumatic fever
No
□ Other
Mental Health Problems:
□ Depression or Anxiety disorder
□ None
□ Schizophrenia
□ Other
□ None
Page 5
Family History
• Mother
• Father
• Brother(s)
• Sister(s)
• Maternal Grandmother
• Maternal Grandfather
• Paternal Grandmother
• Paternal Grandfather
Living
Yes - age_
Yes - age_
Yes - age_
Yes - age_
Yes - age_
Yes - age_
Yes - age_
Yes - age_
Yes - age_
Yes - age_
Cause of Death/Age at Death
No
No
No
No
No
No
No
No
No
No
Disorders in Your Family
Relationship to You
• Breast cancer
• Ovarian cancer
• Colon cancer
• Other cancer_
• Diabetes
• Thyroid problems
• Heart disease
• Blood clots
• Obesity
• Psychiatric problems
• Tuberculosis
• Endometriosis
• Infertility
• Menopause before age 40
• Birth defects
• Cystic Fibrosis
• Tay-Sachs disease
• Canavan disease
• Bloom syndrome
• Gaucher disease
• Niemann-Pick disease
• Fanconi Anemia
• Familial Dysautonia
• Muscular Dystrophy
• Neurologic (brain/spine)
• Neural Tube Defects
• Bone/Skeletal Defects
• Dwarfism
• Developmental delay
• Learning problems
• Polycystic kidney disease
• Heart defect from birth
• Down syndrome
• Other chromosome defects
• Marfan syndrome
• Hemophilia
• Sickle Cell Anemia
• Thalassemia
• Galactosemia
• Deafness/Blindness
• Color Blindness
• Hemochromatosis
• High blood pressure
• Glaucoma
• Gallstones
• Hepatitis
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No Don’t Know
No Don’t Know
No Don’t Know
No Don’t Know
No Don’t Know
No Don’t Know
No Don’t Know
No Don’t Know
No Don’t Know
No Don’t Know
No Don’t Know
No Don’t Know
No Don’t Know
No Don’t Know
No Don’t Know
No Don’t Know
No Don’t Know
No Don’t Know
No Don’t Know
No Don’t Know
No Don’t Know
No Don’t Know
No Don’t Know
No Don’t Know
No Don’t Know
No Don’t Know
No Don’t Know
No Don’t Know
No Don’t Know
No Don’t Know
No Don’t Know
No Don’t Know
No Don’t Know
No Don’t Know
No Don’t Know
No Don’t Know
No Don’t Know
No Don’t Know
No Don’t Know
No Don’t Know
No Don’t Know
No Don’t Know
No Don’t Know
No Don’t Know
No Don’t Know
No Don’t Know
Page 6
What is your Ancestry?
African-American
Native A m e r i c a n
Ashkenazi Jewish
Asian-Chinese
Asian-Japanese
Asian-Korean
Asian-Indian
Asian-Filipino
Asian-Vietnamese
Asian-Other:
Caucasian-Northern European
Caucasian-Russian
Caucasian-Southern European
Hispanic – Mexican
Hispanic – South America Country of
Origin:
Hispanic – Central American Country of
Origin:
Hispanic – Spain
Middle Eastern-Country of
Origin:_
African-Country of Origin:
Other (specify
)
•

Page 7
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? No Yes - For how long?
How often?
• List any antidepressant/antianxiety medications you are currently taking.
• Describe any emotional, marital, or sexual problems caused by your infertility.
PATIENT’S SIGNATURE
DATE
I confirm that I have reviewed the information above.
PHYSICIAN’S SIGNATURE_
DATE
UCSF CENTER FOR REPRODUCTIVE HEALTH ETHNICITY QUESTIONNAIRE
A. Female Patient
1. What is your Ancestry?
..African-American
..African-Country of Origin:
.. Native A m e r i c a n
..Ashkenazi Jewish
..Asian-Chinese
..Asian-Japanese
..Asian-Korean
..Asian-Indian
..Asian-Filipino
..Asian-Vietnamese
..Asian-Other:
..Brazilian
..Cajun
..Caribbean
..Caucasian-Northern European
..Caucasian-Eastern European
..Caucasian-Russian
..Caucasian-Southern European
..French Canadian
..Greek
..Italian
..Portuguese
..Hispanic – Mexican
..Hispanic – South America Country of Origin:
..Hispanic – Central American Country of Origin:
..Hispanic – Spain
..Middle Eastern-Country of Origin:_
..Other (specify
)
2. Were you born in the United States? ..Yes ..No
3. If not, what country were you born in?
4. Is English your native language? ..Yes ..No
5. If not, what is your native language?
Page 8