Microsoft word - rist infertility questionaire.docx

Infertility Questionnaire
Please answer all questions thoroughly and accurately. Fee free to use a separate page, if you need
additional room.
Patient name
Husband/Partner name
How long have you been trying to get pregnant? MENSTRUAL HISTORY
Date of onset of your last menstrual period
Date of onset of your previous menstrual period How many days occur between your menses, usually What is the average amount of flow (<6 or >6 pads or tampons per day) Severe (require pain meds and bed rest) BIRTH CONTROL INFORMATION
Have you ever taken birth control pills? Have you ever had an intrauterine device (IUD)? Do you use vaginal lubricants during intercourse? PREVIOUS PREGNANCIES INFORMATION
What were the outcomes of these pregnancies? PAST HISTORY (please check if any are applicable)
Have you ever had any type of pelvic surgery? Have you ever had surgery or treatments for an abnormal PAP smear? If yes, when and what type of treatment? Do you have any allergies to medications? Are you currently taking any medications? PREVIOUS INFERTILITY STUDIES
Basal body temperatures
Has a post-coital test (PCT) been performed? Has a hysterosalpingogram (X-ray of fallopian tubes) ever been performed? Have you had an endometrial biopsy performed: Have you ever had chromosomal studies performed? Have you had other infertility studies performed? PREVIOUS INFERTILITY TREATMENT
Clomiphene citrate (Clomid, Serophene) with timed intercourse
Clomiphene citrate with intrauterine insemination Gonadotropins (Pergonal, Metrodin, Repronex, Gonal F, Follistim) with timed intercourse Gonadotropins with intrauterine insemination Please document in chronological order information regarding your treatment cycles. Please be detailed as possible. Surgical History
Date Location
Procedure
Findings
Medical History
Problem Date
Diagnosed Treatment
FAMLY HISTORY
Is there a history of breast, colon or ovarian cancer in your family?
Any females with ovarian cysts formation problems? Any females with a problem with uterine fibroids? Any chromosomal abnormalities in the family? Sibling or family history of infertility disorder (please check): Do any diseases run in your family? Do any of your relatives suffer from a major illness? Check one
Comments
Do you have allergies to any medications? Are you currently taking any medication, vitamins or MALE PARTNER DATA

Date of Birth:
Marriage #:

Number of pregnancies conceived with current partner:
Number of pregnancies conceived with previous partners: Please give approximate dates and outcomes of any pregnancies conceived with a previous partner: If you have had a semen analysis, please indicate date and results: Location of
Concentration
Motility (%)
Morphology (%)
Analysis
(million/ml)

Medical History
Problem Date
Diagnosed Treatment

Surgical History
Date Location
Procedure
Findings

Family History (Do any diseases run in your family? Do any of your relatives suffer from a major illness?
Check one
Comments
Does anyone in your family have a history of birth defects? Do you have a family history of recurrent pregnancy loss?
Additional Male Partner Information
Check One
Comments
Do you use recreational drugs or steroids? Do you have difficulties with ejaculation? Are your genitals exposed to excessive heat? Have you had an injury to your genitals? Have you had any infections of your penis or testicles? Have you had an infection of your prostate Have you had an undescended testicle as a PREVIOUS DIAGNOSES WITH EXPECTATIONS
What has been your understanding of your previous diagnoses and expectations for successful treatment? What is your expectation with our office?
Thank you for taking your time to fill out this form!
RIST Team

Source: http://www.conceiveababy.com/pdfs/forms/Infertility%20Questionaire.pdf