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ZOUVES FERTILITY CENTER PATIENT SERVICES 1241 E. HILLSDALE BLVD., SUITE 100, FOSTER CITY, CA. 94404 TOLL FREE: 1-800-800-1160 PHONE: 650-378-1050 FAX: 650-577-1112 IN ORDER TO SCHEDULE A CONSULTATION WITH A DOCTOR, AN OVERVIEW OF YOUR MEDICAL HISTORY AND A COPY OF YOUR MEDICAL RECORDS ARE REQUESTED. THIS WILL INSURE THAT THE DOCTOR CAN ASSESS YOUR INDIVIDUAL CASE DURING YOUR INITIAL CONSULTATION. PLEASE FILL OUT THIS FORM AND EMAIL TO [email protected] OR FAX TO 650-577-1112 THANK YOU! FEMALE CONSULTATION QUESTIONNAIRE LEGAL NAME (PLEASE PRINT)? NAME:________________________________DATE OF BIRTH:_____________________________________ DO YOU PREFER TO GO BY ANOTHER NAME________________________________________________________ WHAT IS YOUR MAILING ADDRESS (INCLUDE CITY, STATE AND ZIP CODE)? WHAT ARE YOUR PHONE NUMBERS? (INCLUDE AREA CODE) HOME: CELL PHONE: E-MAIL ADDRESS: Single Married Unmarried Registered Domestic Partners HOW WERE YOU REFERRED TO US? PHYSICIAN PATIENT RADIO NEWSPAPER WORD OF MOUTH INTERNET OTHER ______________ WHICH PHYSICIAN OR PATIENT IF APPLICABLE________________________________ LAST CONTRACEPTIVE USED: ________________________________STOPPED:__________________________ HAVE YOU DONE ANY ACUPUNCTURE: YES NO__________________________________________________ ACUPUNCTURIST NAME: ___________________________________________ HERBS: ___________________ ARE YOU ALLERGIC TO ANY MEDICATIONS? _________________ ARE YOU CURRENTLY TAKING ANY MEDICATIONS OR SUPPLEMENTS? PLEASE LIST ALL MEDICATIONS AND SUPPLEMENTS _____________________________________________________________________________________ HAVE YOU EVER BEEN PREGNANT (LIVE BIRTH, MISCARRIAGE (SAB), TERMINATION (TAB), CHEMICAL OR ECTOPIC) YES □ NO □ A) TOTAL NUMBER OF PREGNANCIES____ LIVE BIRTH(S) _____ MISCARRIAGE(S) _____ TERMINATION(S) _____ ECTOPIC(S) _____ B) DATES OF PREGNANCY: PLEASE INCLUDE HOW MANY WEEKS, WITH CURRENT OR PREVIOUS PARTNER, RESULT, AND THROUGH NATURAL CONCEPTION OR ASSISTED REPRODUCTION. PREGNANCY #1____________________________________________________________________ PREGNANCY #2____________________________________________________________________ PREGNANCY #3____________________________________________________________________ PREGNANCY #4____________________________________________________________________ PREGNANCY #5____________________________________________________________________ WHAT HAVE THE DOCTORS DIAGNOSED AS THE INFERTILITY PROBLEM? (PLEASE MARK WITH AN X) _____MALE INFERTILITY _____TUBAL DISEASE/PELVIC ADHESIONS _____ENDOMETRIOSIS (MILD, MODERATE OR SEVERE?) _____UNEXPLAINED INFERTILITY IMMUNOLOGY UTERINE OVULATORY DYSFUNCTION _______OTHER DOCTOR’S NAME: _________________________________________YEAR DIAGNOSED ________________ ARE YOU CURRENTLY IN CYCLE WITH ANOTHER FERTILITY CENTER? ___________________________________ FEMALE HISTORY WEIGHT________________________________________HEIGHT_______________________________ HOW OLD WERE YOU WHEN YOU STARTED YOUR MENSTRUATION? ____________________________________ HOW LONG BETWEEN MENSTRUATION (EXAMPLE: EVERY 28 TO 30 DAYS)?______________________________ HOW MANY DAYS DOES YOUR MENSTRUATION LAST (ACTUAL DAYS OF BLEEDING)? _________________________ HAVE YOU BEEN DIAGNOSED WITH ANY OVULATION PROBLEMS OR HORMONAL IMBALANCES? __________________ HAVE YOU BEEN TESTED FOR THE FOLLOWING HORMONES? IF YES, MARK ANY ABNORMAL OR NORMAL RESULTS. FOLLICLE STIMULATING HORMONE (FSH) __________ESTRADIOL(E2)_________________________________ THYROID HORMONES (TSH)___________________ ANTI-MULLERIAN HORMONE(AMH)___________________ PROLACTIN______________________________ PROGESTERONE_________________________________ HAVE YOU EVER UNDERGONE ONE OR MORE OF THE FOLLOWING PELVIC SURGERIES? SURGERY TO REPAIR OVARIES OR UNBLOCK TUBES YES NO __________________________________ ECTOPIC PREGNANCY/SURGERY YES NO _______________________________________________ TUBAL LIGATION YES NO _________________________________________________________ ENDOMETRIOSIS (STAGE I, II, OR III)? (PLEASE CIRCLE) YES NO _____________________________ REMOVAL OF SCAR TISSUE, POLYPS, CYSTS, ETC. FROM INSIDE OF UTERUS YES NO __________________ REMOVAL OF FIBROIDS FROM UTERUS YES NO ___________________________________________ HYSTERECTOMY/REMOVAL OF OVARIES YES NO __________________________________________ HAVE YOU EVER HAD A HYSTEROSALOPINOGRAM (HSG)? (DYE IS INSERTED INTO TUBES AND AN X-RAY IS PERFORMED). IF YES, WHAT YEAR WAS THE TEST PERFORMED AND WHAT WERE THE FINDINGS? WERE THE TUBES CLEAR BLOCKED? ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ DOCTOR’S NAME _____________________________________YEAR ______________________________ 2 HAVE YOU HAD A LAPAROSCOPY? (THIS IS A MINOR SURGERY. A SMALL INCISION IS MADE NEAR THE BELLY BUTTON). IF YES, WHAT YEAR AND WHAT WERE THE FINDINGS? __________________________________________________________________________________ __________________________________________________________________________________ DOCTOR’S NAME ____________________________________ YEAR _____________________________ HAVE YOU HAD A HYSTEROSCOPY? (THIS IS A NON-SURGICAL MEANS OF LOOKING AT THE MUSCLE WALL OF THE UTERUS. A TELESCOPIC INSTRUMENT IS INSERTED VAGINALLY). IT IS NOT AN ULTRASOUND. IF YES, WHAT YEAR AND WHAT WERE THE FINDINGS? __________________________________________________________________________________ __________________________________________________________________________________ DOCTOR’S NAME ____________________________________ YEAR _____________________________ HAVE YOU HAD A HYSTERO-ULTRASONOGRAM (HUS)? (STERILE WATER IS INSTILLED INTO THE UTERINE CAVITY AND AN ULTRASOUND SCANNER CHECKS FOR POLYPS OR FIBROIDS) __________________________________________________________________________________ __________________________________________________________________________________ DOCTOR’SNAME_____________________________________YEAR______________________________ HEALTH HISTORY HOT FLASHES YES______ ASTHMA YES______ HEPATITIS YES______ CANCER YES______ RHEUMATOID ARTHRITIS YES______ LUPUS YES______ DES EXPOSURE YES______ PELVIC INFLAMMATORY DISEASE YES______ INTRAUTERINE DISEASE (IUD) YES______ EXPOSURE TO TB YES______ POSITIVE PPD PURIFIED PROTEIN DERIVATIVE YES___ ENDOMETRIOSIS YES______ SEXUALLY TRANSMITTED DISEASES YES______ VISUAL DISTURBANCES YES______ THYROID DISORDER YES______ INCREASED FACIAL OR BODY HAIR YES______ INCREASED ACNE YES______ WEIGHT GAIN OR LOSS OF 10 LBS YES______ HIGH BLOOD PRESSURE YES______ DIABETES YES______ AUTO IMMUNE DISEASE YES______ PSYCHIATRIC TREATMENT YES______ SEIZURES YES______ NO_____ NO_____ NO_____ NO_____ NO_____ NO_____ NO_____ NO_____ NO_____ NO_____ NO_____ NO_____ NO_____ NO_____ NO_____ NO_____ NO_____ NO_____ NO_____ NO_____ NO_____ NO_____ NO_____ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ 3 FAMILY HISTORY ETHNIC ORIGIN/ANCESTRY MOTHERS ANCESTRY: ___________ FATHER: ______________________________ DO YOU HAVE ANY OF THE FOLLOWING HERITAGES? PLEASE X IN THE BOX BELOW JEWISH MEDITERRANEAN I.E. (ITALIAN, GREEK) FRENCH CANADIAN SOUTH EAST ASIAN AFRICAN ANCESTRY CAJUN PLEASE LIST-- MATERNAL/PATERNAL GRANDMOTHER, GRANDFATHER, MOTHER, FATHER, BROTHER, SISTER, AUNT OR UNCLE, ETC. THYROID DISEASE RHEUMATOID ARTHRITIS LUPUS OTHER AUTO IMMUNE RECURRENT MISCARRIAGE DIABETES HIGH BLOOD PRESSURE HEART DISEASE STROKE COLON CANCER OVARIAN CANCER BREAST CANCER PROSTATE CANCER CANCER (OTHER) CANCER (OTHER) NEURAL TUBE DEFECT PREMATURE MENOPAUSE UTERINE FIBROIDS ENDOMETRIOSIS YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES ___________________________ ______ ___________________________ ____________________________ ______ ____________________________ ____________________________ ______ ___________________________ ____________________________ ___________________________ ___________________________ ____________________________ ____________________________ ___________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ___________________________ ___________________________ NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO NO Hereditary Conditions THALASSEMIA TAY - SACHS DISEASE SICKLE CELL ANEMIA CYSTIC FIBROSIS MUSCULAR DYSTROPHY HUNTINGTON’S CHOREA MENTAL RETARDATION FRAGILE X BABY WITH BIRTH DEFECTS BLEEDING DISORDER AUTISM YES YES YES YES YES YES YES YES YES YES YES ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ NO NO NO NO NO NO NO NO NO NO NO 4 PAST FERTILITY TREATMENT 25. HAVE YOU BEEN TREATED WITH THE FOLLOWING? CLOMID/SEROPHENE/FEMERA: ______________________ IF SO, HOW MANY CYCLES TOTAL? ______________ INJECTABLE GONADOTROPINS: ______________________ IF SO, HOW MANY CYCLES TOTAL? _____________ 26. HAVE YOU UNDERGONE AN IUI CYCLE(S) IF SO, PLEASE LIST EACH CYCLE BELOW: CYCLE DATE MEDS OUTCOME DR. & LOCATION 1 2 3 4 5 6 7 8 9 5 IVF HISTORY PLEASE LIST EACH INDIVIDUAL IVF, FET OR ANY CANCELLED CYCLES INDICATE IF YOU USED YOUR OWN EGGS, EGG DONOR, SPERM DONOR, AND/OR SURROGATE, OR CYCLE WAS A FROZEN EMBRYO TRANSFER. PLEASE INCLUDE CANCELLED CYCLE(S) OR CYCLE(S) THAT TURNED TO IUI. CYCLE # ____________DATE ________________________________________________ FERTILITY CENTER _________________________________________________________ FRESH CYCLE -FROZEN CYCLE _____________________________________________________________ WHAT FERTILITY MEDICATIONS OR PROTOCOL? ________________________________________________ HOW MANY EGGS RETRIEVED? _____________________________________________________________ HOW MANY FERTILIZED? _______ ICSI ______SPLIT/ICSI_____ASSISTED HATCHING ____PGD/CCS________ HOW MANY TRANSFERRED? _______________________DAY TRANSFERRED__________________________ HOW MANY FROZEN? ___________________________________________________________________ WAS THIS CYCLE CONVERTED TO IUI OR CANCELLED: YES NO____________________________________ OUTCOME: POSITIVE NEGATIVE CHEMICAL MISCARRIAGE ECTOPIC _______________________ CYCLE # ____________DATE ________________________________________________ FERTILITY CENTER _________________________________________________________ FRESH CYCLE -FROZEN CYCLE _____________________________________________________________ WHAT FERTILITY MEDICATIONS OR PROTOCOL? ________________________________________________ HOW MANY EGGS RETRIEVED? _____________________________________________________________ HOW MANY FERTILIZED? _______ ICSI ______SPLIT/ICSI_____ASSISTED HATCHING ____PGD/CCS________ HOW MANY TRANSFERRED? _______________________DAY TRANSFERRED__________________________ HOW MANY FROZEN? ___________________________________________________________________ WAS THIS CYCLE CONVERTED TO IUI OR CANCELLED: YES NO____________________________________ OUTCOME: POSITIVE NEGATIVE CHEMICAL MISCARRIAGE ECTOPIC _______________________ CYCLE # ____________DATE ________________________________________________ FERTILITY CENTER _________________________________________________________ FRESH CYCLE -FROZEN CYCLE _____________________________________________________________ WHAT FERTILITY MEDICATIONS OR PROTOCOL? ________________________________________________ HOW MANY EGGS RETRIEVED? _____________________________________________________________ HOW MANY FERTILIZED? _______ ICSI ______SPLIT/ICSI_____ASSISTED HATCHING ____PGD/CCS________ HOW MANY TRANSFERRED? _______________________DAY TRANSFERRED__________________________ HOW MANY FROZEN? ___________________________________________________________________ WAS THIS CYCLE CONVERTED TO IUI OR CANCELLED: YES NO____________________________________ OUTCOME: POSITIVE NEGATIVE CHEMICAL MISCARRIAGE ECTOPIC _______________________ CYCLE # ____________DATE ________________________________________________ FERTILITY CENTER _________________________________________________________ FRESH CYCLE -FROZEN CYCLE _____________________________________________________________ WHAT FERTILITY MEDICATIONS OR PROTOCOL? ________________________________________________ HOW MANY EGGS RETRIEVED? _____________________________________________________________ HOW MANY FERTILIZED? _______ ICSI ______SPLIT/ICSI_____ASSISTED HATCHING ____PGD/CCS________ HOW MANY TRANSFERRED? _______________________DAY TRANSFERRED__________________________ HOW MANY FROZEN? ___________________________________________________________________ WAS THIS CYCLE CONVERTED TO IUI OR CANCELLED: YES NO____________________________________ OUTCOME: POSITIVE NEGATIVE CHEMICAL MISCARRIAGE ECTOPIC _______________________ PLEASE NOTE ANY OTHER ITEMS THAT YOU WOULD LIKE TO HAVE DR. ZOUVES REVIEW: 6
