Patient’s Medical History

PART 1: DEMOGRAPHICS


Female

Full Name *
Date of birth *
Occupation *
Address *
Health Insurance *
Height *
Weight *
Telephone Number *

Male (if exists)

Full Name
Date of birth
Occupation
Address
Health Insurance
Height
Weight
Telephone Number

PART 2: GYNAECOLOGICAL HISTORY & OTHER INFORMATION

REASON FOR SEEING US
Fertility Evaluation(for how months have you been trying to conceive?)Recurrent MiscarriagesGenetic CheckOther
Comments
PREGNANCY HISTORY
Total number of pregnancies:
Pregnancies that came to term:
Ectopic pregnancies
Miscarriages (week)/ or Termination
MENSTRUATION HISTORY
Menstrual Cycles (check all that apply to you):
Regular periodIrregular periodHeavy periodLight periodAmenorrheaHemorrhage between periodsSpotting before period
Number of days between periods:
How many days does your period last?
Age your first period started:(ετών)
How many periods do you have per year?
Have you ever taken pharmaceuticals to get your period?YesNo
Do you cramp?YesRarelyNo
CONTRACEPTION HISTORY
NoneCondomsDiaphragmIUD / SpiralPatchTubal ligation / TubectomyOral contraception
If you have chosen "Tubectomy or Oral contraception", please write down the dates and possible complications/side effects
VAGINAL & CERVICAL CULTURE TEST
Fungi/Yeast InfectionEcoliMycoplasmaChlamydiaBacterial VaginosisProteusUreaplasmaOtherNone
Please write down the treatment you received
PAP TEST
When was your last PAP smear?

Any history of:HPV InfectionGenital WartsNone
Comments & Dates, if there is any history

ResultNormalIrregular
Comments

Have you had any surgery done due to the results of your PAP test?
NoYesColposcopyLoop excisionLaserCryotherapy
BREAST CHECK-UP
Have you ever had a mammography?NoYes (date)
(second last)
Results:normalabnormal
Comments/Details(if your answer is abnormal)

Do you self-exam your breasts?NoYes
MEDICAL HISTORY
Do you have any medical conditions/diseases?NoYes
Please specify mentioning dates and treatment, if your answer is yes

Are you allergic to any medication?NoYes
Please specify and describe reactions, if your answer is yes

Are you allergic to any food (peanuts, eggs etc)?NoYes
Please specify and describe reactions, if your answer is yes

Describe any drags / vitamins / supplements you are currently taking
SOCIAL HISTORY
How many drinks containing caffeine (coffee, tea, soft drinks) do you consume daily?

Do you smoke?NoYes (per day)(for how many years)
Do you consume alcohol?NoYes (glasses / week)
SEXUAL BEHAVIOR
How many times do you engage in sexual intercourse?
Have you used an ovulation test?NoYes
Do you have pain during intercourse?NoYes
Do you use lubricants?NoYes(what kinds?)
Have you been exposed to STDs or pelvic infections?
NoHepatitisHIV/AidsSyphilis / GonorrheaHerpes
Please specify the treatment you received
OPERATION HISTORY
Have you ever had any surgery done?NoYes
List all procedures in chronological order (Cause and type of procedure / Dates)
HISTORY OF ANAESTHESIA
Have you ever had any problem with/during anaesthesia?NoYes
Specify the problem, if you answered yes

PART 3: COUPLE'S MEDICAL HISTORY

Have any members of your immediate family had any difficulty in conceiving?NoYes
Specify the problem, if your answer is Yes
FAMILY DISEASES

Breast cancer
FEMALEYesNoDon't know
MALEYesNoDon't know
Ovary cancer
FEMALEYesNoDon't know
MALEYesNoDon't know
Colon cancer
FEMALEYesNoDon't know
MALEYesNoDon't know
Other malignancies
FEMALEYesNoDon't know
MALEYesNoDon't know
Diabetes Mellitus
FEMALEYesNoDon't know
MALEYesNoDon't know
Diseases of thyroid
FEMALEYesNoDon't know
MALEYesNoDon't know
Cardiac disease / Congenital heart disease
FEMALEYesNoDon't know
MALEYesNoDon't know
Thrombotic diseases
FEMALEYesNoDon't know
MALEYesNoDon't know
Obesity
FEMALEYesNoDon't know
MALEYesNoDon't know
Psychiatric conditions
FEMALEYesNoDon't know
MALEYesNoDon't know
Endometriosis
FEMALEYesNoDon't know
MALEYesNoDon't know
Menopause before 40 or 45
FEMALEYesNoDon't know
MALEYesNoDon't know
Thalassemia (πχ. Heterozygous Thalassemia)
FEMALEYesNoDon't know
MALEYesNoDon't know
Cystic Fibrosis
FEMALEYesNoDon't know
MALEYesNoDon't know
Polycystic Kidney Disease
FEMALEYesNoDon't know
MALEYesNoDon't know
Down Syndrome
FEMALEYesNoDon't know
MALEYesNoDon't know
Other chromosomal abnormalities
FEMALEYesNoDon't know
MALEYesNoDon't know
Other
FEMALEYesNoDon't know
MALEYesNoDon't know

PART 4: MALE MEDICAL HISTORY & INFORMATION

MEDICAL HISTORY
Have you been diagnosed with any of the following?
Diabetes Mellitus YesNo
Multiple Sclerosis YesNo
Ulcer / gastritis YesNo
Cancer YesNo
Neurological problems YesNo
U.T.I. YesNo
Eleveated blood pressure YesNo(treatment)
Thyroid disease YesNo(treatment)
Have you undergone hernia surgery?YesNo
Are you exposed to prolonged heat at work?YesNo
Are you exposed to radiation or chemical substances at work?YesNo
Have you gone through chemotherapy?YesNo
Are you allergic to any medication drugs?YesNo
Please specify and describe reactions, if you answered yes.

Are you on any medication at the moment?YesNo
Write down the type of medication, if you answered yes.
MALE MEDICAL HISTORY
Have you been examined by an urologist?NoYes
Have you ever had a semen analysis?NoYes
Have you impregnated any other woman?NoYes(how many times?)
Do you have an erection problem?NoYes
Have you been exposed to STDs or pelvic infections?
NoHepatitisHIV/AidsSyphilisHerpesGonorrheaOther
Describe the treatment, if your answer is Yes.

Have you undergone surgery for varicocele?NoYes
Did you have cryptorchidism?NoOne sideBoth
Do you have scrotum or testicle pain?NoYes
Did you have the mumps after puberty?NoYes
Did you have testicular injury that required hospitalization?NoYes
Have you ever had prostatitis?NoYes
SOCIAL HISTORY
How many drinks containing caffeine (coffee, tea, soft drinks) do you consume daily?

Do you smoke?NoYes (per day)(for how many years)
Do you consume alcohol?NoYes (glasses / week)

BeerWineVodka/whiskey
Do you take medication / vitamins / supplements?NoYes
Have you been exposed to radiation / toxic material?NoYes
HISTORY OF MALE OPERATIONS
Have you ever had any surgery done?NoYes
List all procedures in chronological order (Cause and type of procedure / Date)
HISTORY OF ANAESTHESIA
Have you ever had any problem with/during anaesthesia?NoYes
Specify the problem

PART 5: EMOTIONAL STATUS

On a scale of 1-10 (10 being the worst), what would you estimate your stress level to be?
Would you like to visit the psychological Support Advisor of Assisting Nature?NoYes
Describe any emotional, family or sexual problems caused by your infertility

PART 6: INFERTILITY AND THERAPY HISTORY (if there has been any)

Have you been through testing or procedures elsewhere? If YES where;

Have you ever taken clomiphene citrate while sexually active? If YES, maximum dose; (tablets/day)

How many cycles?
Have you ever undergone intrauterine insemination?
YesNoUsing gonadotropin (injections)using Clomiphene
Specify (No. of cycles - Date)

Report previous IVF treatments (fresh and frozen eggs)
(Please mention the below data: No. / IVF Unit / Date / Protocol (Dose - Drugs) / Egg Number / Fertilised eggs / Transferred eggs / Pregnancy(yes or no) )

Extra information / Complications

Have you had an IVF attempt cancelled?

The information above is confidential. It is to be exclusively used for the legal person to whom they are addressed. Assisting nature has a policy for the proper use of all sensitive personal data and in accordance with the permission of the DPA sensitive personal data.