Microsoft word - history form computer complete.doc

COLORADO REPRODUCTIVE ENDOCRINOLOGY
4600 HALE PARKWAY, SUITE 350
PATIENT NAME:
DENVER, CO 80220
303-321-7115 FAX 303-321-9519
ATIENT HISTORY FORM
PHYSICIAN:

Please answer the fol owing questions to the best of your ability. The information obtained wil enable us to provide you with optimal medical
care. If you do not know the answer to any questions, you may leave it blank. This form should take about 15-20 minutes to complete. It can
be completed on the computer and then printed out or printed out and filled in by hand. To fill this out online, simply use your mouse and
click on the grey shaded areas. Clicking on a “check box” will put an “X” in that box or will remove an “X” placed there by mistake. The
rectangular grey shaded boxes require you to type in the information. Click on that box and begin typing.
IDENTIFYING INFORMATION
DATE OF VISIT:
Emergency contact, alternate address and phone number (where we can reach you if any tests come back abnormal or in an emergency, if different than above): Gynecologist’s name (if different from referring doctor):
PLEASE DESCRIBE AS THOROUGHLY AS POSSIBLE YOUR PRESENT PROBLEM:

MENSTRUAL HISTORY
When did your most recent period begin? If No, how many times per year do you have your period? How long is your entire cycle (i.e. from the first day of one period to the first day of the next period)? How many days do you usually bleed during your period? Days of bleeding: How many pads or tampons do you use on your heaviest day? Do you have cramps or pain before, during, or after your period? Do you have to take pain medication for cramps? Do you have premenstrual symptoms such as breast tenderness, bloating, etc. that let Have you noticed a change in your periods recently? Do you bleed or spot between periods or after intercourse? Have other members of your family had difficulty with conception or pregnancy?
CONTRACEPTIVE/SEXUAL/MARITAL HISTORY
Are you currently trying to get pregnant? If Yes, how long have you tried to conceive? What form of contraceptive have you used in the past? (check all that apply) Have you ever had problems using birth control (i.e., high blood pressure, allergy to condoms, etc.)? How often did you and your partner have sexual relations during the past month? Have you ever had unprotected intercourse (for more than 6months) with another partner and How many sexual partners have you had in the past 2 years? Do you notice any pain with intercourse? Have you ever had a sexually transmitted disease or pelvic inflammatory disease? Have you ever had an abnormal PAP smear? Do you have any pain you wish to discuss with your doctor?
PREGNANCY HISTORY
How many times have you been pregnant (including miscarriages and abortions)?
PLEASE COMPLETE THE FOLLOWING CHART:
*VAGINAL DELIVERY (V), C-SECTION (CS), MISCARRIAGE (M), ABORTION (A), ECTOPIC PREGNANCY (EP)
WAS INFERTILITY
HOW LONG TO
IS THE CURRENT OR PAST
SEE CHOICES
THERAPY NEEDED
CONCEIVE
PARTNER THE FATHER OF
WEIGHT OF CHILD
THE CHILD?

Were there any complications during or after your pregnancies?
If Yes, explain (i.e., preterm labor, bleeding, gestational diabetes, high blood pressure):
HISTORY OF FERTILITY TESTING AND THERAPY
If applicable, check all of the following medications that you have taken in the past in an attempt to conceive: Progesterone suppositories/oral progesterone/progesterone Gonadotropin Injections (Pergonal, Humegon, Repronex, Follistim,
MEDICAL HISTORY
Do you have any allergies to medications?
Within the last year, have you taken any prescription medications?
If Yes, list all the medications and problems for which you were taking them. MEDICATION
DATE STARTED
DATE STOPPED
Are you taking any non-prescription medications on a regular basis (including medicines such as aspirin, Tylenol,
ibuprofen, water pills, laxatives, herbal medications, dietary supplements, vitamins, etc.)?
If Yes, please list name of medication and dose. MEDICATION

SURGICAL HISTORY


Have you ever had surgery?
If Yes, specify year, type of surgery performed, and location of surgery: TYPE OF SURGERY
HOSPITAL/CITY

Have you ever been hospitalized for something other than childbirth or surgery?
If Yes, specify the reason for admission. DATE (MONTH/YEAR)
REASON FOR ADMISSION
HOSPITAL/CITY

FEMALE PARTNER’S FAMILY HISTORY
Is there a family history of: (check all that apply)
SOCIAL AND DIETARY HISTORY
Do you use or have you ever used: (check all that apply) How many glasses per week do you usually drink? Wine: In your current or previous employment, have you ever been exposed to toxins, Have you used illicit or recreational drugs in the last year? Has your weight changed more than 15 lbs. in the last year? If Yes, specify (i.e., vegetarian, low salt, low cholesterol): Do you feel that you eat a well-balanced diet? Have you ever been diagnosed with an eating disorder such as anorexia nervosa or bulimia? List the forms and frequency of regular vigorous exercise (swimming, cycling, running; if you do not exercise on a regular basis, check "none"): Do you often feel sad, depressed, or irritable? REVIEW OF SYSTEMS
DO YOU HAVE OR HAVE YOU EVER HAD: (check all that apply)
NEUROLOGICAL PROBLEMS:
HORMONE PROBLEMS:
Excessive hunger or thirst Hot flashes or unexplained cold spells Other: EYE/EAR/NOSE/THROAT PROBLEMS:
MUSCLE OR BONE PROBLEMS:
HEART OR BLOOD VESSEL PROBLEMS:
STOMACH OR INTESTINAL PROBLEMS:
Unusual amounts of constipation or diarrhea Spastic colon/ulcerative colitis Hernia Other: LUNG/BREATHING PROBLEMS
BLOOD DISORDERS:
PELVIC OR URINARY PROBLEMS:
Chlamydia/gonorrhea/venereal disease/PID Syphilis/herpes Genital warts/HPV Other: MENTAL HEALTH
ALLERGIC/AUTOIMMUNE
Hospitalizations for mental illness Other: NONE OF THE ABOVE
PARTNER’S HISTORY

If you are seeing the doctor for fertility, please have your partner complete these questions.
PARTNER’S IDENTIFYING INFORMATION
Do you get exposed to toxins or radiation at your job?
MEDICAL HISTORY
Allergies (medications and environmental): If Yes, specify year, type of surgery, and location of surgery: TYPE OF SURGERY
HOSPITAL/CITY
Have you ever had x-rays of the pelvic area? Are you or have you been exposed to any of the following during recreation, employment, or military service? Extreme heat (since trying to conceive) Within the last year, have you taken any prescription medications? If Yes, list all prescriptions and problems for which you were taking them: MEDICATION
DATE STARTED
REASON FOR TAKING
Are you taking any nonprescription medications on a regular basis? (including medicines such as aspirin, Tylenol, laxatives, etc.) Do you use or have you ever used: (check all that apply) Alcohol How many glasses per week do you usually drink? Wine: Cigarettes Number of cigarettes per day: Illicit or recreational drugs (marijuana, cocaine, etc.) since trying to conceive
PARTNER’S FAMILY HISTORY
Is there a family history of infertility? Is there a family history of hereditary disorders (in yourself, your parents, your partner, or your children): (check all that apply)
If your partner is male, please fill out this section too:

SEXUAL HISTORY
When you were a child, were both testes descended into the scrotum? How many pregnancies have you produced with your current partner? Have you ever produced a pregnancy with another partner? If Yes, how long did it take to conceive? Did you ever have infertility or difficulty conceiving with a previous partner? Do you have trouble getting an erection? Do you have trouble maintaining an erection? Have you noticed a change in your sexual drive recently?
HISTORY OF FERTILITY THERAPY
Have you ever been treated for urological problems or infertility before? Have you taken any of these drugs in the past? (check all that apply)
OTHER ISSUES YOU OR YOUR PARTNER WISH TO ADDRESS WITH YOUR PHYSICIAN:

Source: http://coloradofertility.com/wp-content/uploads/2013/01/Patient-History-Form.pdf