If you are coming to see us for the first time it would be useful to fill out an evaluation form to help us understand how best to help you. Please note that email is not a 100% secure mean of communication. If you prefer to fill out the form in printable format, please click here and bring it with you on your next apppointment date.
Please complete and bring this questionnaire before your first 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
How would you describe the cramps? Mild Moderate Severe
Do you take pain medication for the cramps? Yes 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 : Cryotherapy(freezing of cervix) Laser therapy
Cone biopsy LEEP 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
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/ per Month (circle)
How frequently do you and your partner have intercourse around ovulation?
times per month
Do you usually use lubrication during intercourse? Yes No
If yes, please specify:
Have you experienced any difficulties with intercourse that may be contributing to infertility?
Yes No If yes, please explain:
Have you ever used contraception in the past? Yes No
if yes, please check all that apply:
Contraceptive pills Condoms IUD Foam/Sponge Rhythm
Withdrawal Other
FERTILITY EVALUATION
How long have you and your partner been attempting to achieve pregnancy?
Have you been using temperature charts? Yes No
If yes, for how long? months
Have you been using urine ovulation predictors
Yes No if yes, what kind and for how long?
Have you ever tried to achieve a pregnancy with a different partner Yes No
Have you ever conceived with a different partner? Yes No
Has your male partner ever gotten someone else pregnant? Yes No
Have you been treated for infertility previously
Yes No If Yes, where/when:
What was the cause of infertility?
Which of the following tests have allready been performed?
Infection test (mycoplasma,Chlamydia) Postcoital test Endometrial biopsy
Hysteroscope
Hormonal tests Antichlamydia Antibody Ultrasound Sonohysterogram
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) Estrogens
steroids (prednisone, dexamethasone) GnRH Antagonist (Antagon)
Bromocriptine (Parlodel, Dostinex)
Glucophage (Metformin) Progesterone Heparin
Baby aspirin Danazol
Have you ever had Intrauterine inseminations (IUI)? Yes No
if so, for how many cycles? cycles
If yes, specimen was provided by : Check all that apply) Partner Donor
Have you ever attempted in vitro fertilization? Yes No if yes, please specify below :
_
OBSTETRICAL HISTORY
Have you ever been pregnant (including elective terminations, miscarriages, births?
Yes No Details
PAST MEDICAL HISTORY
Do you have or have you ever had any of the following (check all that apply):
Ovarian cysts Anemia Endometriosis Gallbladder disease Arthritis
Heat/cold intolerance hair loss Seizures high blood pressure mumps
Hirsutism (excess hair growth) hot flashes vision problems
Cystic Fibrosis Diabetes Breast (Nipple discharge)
Colitis Acne chronic headaches Kidney /Liver problems German Measles
Regular Measles Neurological problems Autoimmune disease (e.g. Lupus)
Immunizations: Tetanus Hepatitis B German Measles Polio
Mumps Chicken Pox Hepatitis B or C
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 Ovarian cancer
Infertility DES exposure in utero/early menopause
Heart disease colon/breast CA
diabetes Thyroid disease
REVIEW OF SYSTEMS
Have you noted any significant:
Heat/Cold intolerance recently? Yes No if yes, please explain:
Unusal hair distribution changes or breast nipple discharge ? 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?
Do you take hot baths?
Do you drink alcohol Yes No if yes, how many alcoholic beverages per week:
Do you smoke marijuana Yes No if yes, how much per week:
Do you exercise regularly? Yes 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 Yes No
Medications Reason
Do any of you use herbal medications? Yes No
if yes, types of medications used:
Which of the following test have already been performed?
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 hernia repair prostate surgery testicular torsion repair
testicular biopsy vasectomy reversal other (please specify):
Have you ever had any significant testicular injury? Yes No If yes, please describe:
Have you ever taken any of the medications listed below?:
Clomiphene (Clomid,Serophene) Propecia Testosterone Viagra
GnRH agonist (Lupron,Synarel,Zoladex Bromocriptine (Parlodel, Dostinex)
Other (please list):
Cystic Fibrosis Delay of puberty Anemia Arthritis Cancer
Autoimmune disease Heat/cold intolerance Seizures Neurological problems
high blood pressure vision problems Testicular tumor
chronic headaches Kidney /Liver problems Colitis Cystic Fibrosis q Diabetes
Regular Measles German Measles mumps Mumps with testes involved
Immunizations:
Tetanus Hepatitis B German Measles Polio Mumps Chicken Pox
Hepatitis B or C
Have you ever had any surgeries in the past Yes No
If yes, please indicate date, type, findings of surgery:
