Please complete and bring this questionnaire before your first prenatal 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

What treatment did you receive? ________________Year:____

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/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

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:

_____________________________________________

Unusual 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: ________

SECTION FOR MALE PARTNER

FERTILITY EVALUATION

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) Proxeed Testosterone Viagra

GnRH agonist (Lupron,Synarel,Zoladex Bromocriptine (Parlodel, Dostinex)

Other (please list): _________

Do you have or have you ever had any of the following (check all that apply):

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

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 ________________ Prostate CA ___________

Heart disease _____________ colon/breast CA __________

diabetes ____________ Other ___________

REVIEW OF SYSTEMS

Have you noted any significant:

Heat/Cold intolerance recently? Yes No if yes, please explain:

_____________________________________________

Unusual hair distribution changes? 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 drink alcohol Yes No No if yes, how many alcoholic beverages per week: __________

Do you smoke marijuana Yes No if yes, how much per week: ________

Do you take hot baths 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 MEDICATIONS

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: ________