Female Infertility Patient Questionnaire printable pdf download

Female Infertility Patient Questionnaire

Identifying Information

Date __________________

Name________________________________________ Partner's Name____________________________________________

Address______________________________________________________________________________________________

Telephone Number-Day (

)

Evening (

)

Cell (

)

Date of Birth__________

Partner's Date of Birth____________

Age _________

Partner's Age _________

Duration of Relationship _____yr. ____mo.

Duration of Infertility ____yr. ____mo.

Occupation ______________________________________ Partner's Occupation ___________________________________

Who referred you? ! Physician __________________

! Former Patient/Friend ________________________________

! Web Site __________________

! Insurance (name of insurance) __________________________

! Radio Interview_____________

! Direct Mail _________________________________________

Who is your Ob/Gyn? ____________________________ Who is your Primary Care Physician? ______________________

Location of Office of Referring physician? __________________________________________________________________

What are your expectations for this visit? ___________________________________________________________________

What questions do you want answered this visit?______________________________________________________________

_____________________________________________________________________________________________________

How many pregnancies (including abortions) have you had? ___________

II. Medical History

Weight ___________ Height ___________ Blood Type (if known) __________

Yes

Have you lost greater than 20 lbs in the last year?

Do you follow any particular diet or have any special dietary habit?

If yes, specify_______________________________________________________________

List the forms and frequency of regular vigorous exercise you do and how long you have been doing it

Exercise

Hrs / Wk

Since When?

Do you have or have you ever had: (check all that apply)

! Anemia

! Gonorrhea

! Pneumonia

! Appendicitis

! Heart Disease

! Poor sense of Smell

! Arthritis

! Hepatitis

! Rheumatic Fever

! Blood Transfusion

! Herpes

! Breast Milky Discharge

! Hypertension

! Seizures

! Breast Soreness/Tenderness

! Excess Hair Growth

! Syphilis

! Kidney Infection

! Thyroid Problems

! Chlamydia

! Liver Problems

! Tuberculosis

! Chronic Bronchitis

! Loss of balance

! Ulcers

! Chronic Headaches

! German Measles

! Pelvic Infection (PID)

! Colitis

! Measles: Regular

! Gallbladder Problems

! Mycoplasma

! Diabetes

! Neurological Problem

! Venereal Disease

! Dizziness

! Visual Disturbances

! Endometriosis

! Ovarian Cyst

! Epilepsy

! Nongonococcal Urethritis

! Immunization to German Measles

! Sexually Transmitted Disease

! Vaginitis (Trichomoniasis, yeast) # of episodes __________

! Allergies: List_____________________________________________________________________________________

Female Infertility Patient Questionnaire

Related Articles

Related forms

Related Categories