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.