FEMALE INFORMATION
Name: _____________________________________________
Birth date: ____________________________ Age: ________
Occupation: _________________________________________
Term births: ________________________________
How long have you been trying to achieve a pregnancy? ________ months of unprotected intercourse How long have you been trying to achieve a pregnancy with current partner? ________ months
PREGNANCY INFORMATION Months to Difficulty Fertility Treatment? Delivery Type Partner? Conception Conceiving?
_________________________ Miscarriage
_________________________ Miscarriage
_________________________ Miscarriage
_________________________ Miscarriage
Please check here, if you have had more than four pregnancies.
MENSTRUAL CYCLE HISTORY (Answer these questions about your menstrual (bleeding) pattern). At what age did you begin having periods? ________ years old When was the date of your last menstrual period? ________ mm/dd/yyyy What is the average length of time your period lasts? ________ days of flow What is the average length of time from the start of one period until the start of the next? ________ days Within the last year, have your periods usually come (without medication) every 26-32 days? Yes No
If no, have your periods always been irregular? Yes No
Do you ever have bleeding in between periods? Yes No
Do you currently need to take medication in order to get a period? Yes No
Premarin Estrace Birth Control Pills Progesterone (if Progesterone, please specify type, below:)
Provera Cycrin Aygestin Crinone Prometrium Other: ________________________________
Do you have pelvic pain with your periods? Yes No
If yes, please indicate the level of pain that you usually experience:
Do you often experience pelvic pain in between periods? Yes No
If yes, do you take medication for pain? Yes No
If yes, which one(s)? ____________________________________________________
If yes, does the medication relieve pain? Yes No
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Have you ever used home ovulation predictor kits? Yes No
If yes, what evidence for ovulation did you see? ( A positive test Color change Other: _____________________
If yes, what day or range of days does it turn positive on? ________ (Example: Day 14-15)
Have you ever used any contraceptives? Yes No
Intrauterine device (IUD) Tubal Ligation (Tubes tied)
Are you currently using any contraceptives? Yes No
Intrauterine device (IUD) Tubal Ligation (Tubes tied)
GYNECOLOGIC HISTORY
If not, when was the last pap done? ________________ mm/dd/yyyy
Have you ever had an abnormal pap? Yes No
If yes, what was the abnormality? ____________________________
If not, when the last mammogram was done? ________________ mm/dd/yyyy
Do you have any breast discharge? Yes No Do you currently have acne? Yes No
Do you have unwanted (facial, arm, chest, or other male pattern) hair growth that requires cosmetic removal? Yes No
Heterosexual Homosexual Never been sexually active
What is the number of sexual partners you have had in the past 2 years? _______
Do you have a history of sexual abuse? Yes No
If yes, have you received counseling Yes No
Would you like us to make a referral for counseling? Yes No
Do you often have pain with intercourse? Yes No
How frequently do you have intercourse? ___________per week
Have you ever had any of the following procedures performed?
Procedure Date (Mo/Yr) Findings Procedure Date (Mo/Yr)
Have you had any exposure to or have been treated for any sexually transmitted disease or pelvic infection? Yes No
MEDICAL HISTORY
Do you have long-standing medical conditions? Yes No
Medical Condition Comments/Findings
Please check here, if you have more than five medical conditions.
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Have you ever needed or used thyroid medication? Yes No
Synthroid Levoxyl Other: _________________
Are you currently taking any medication? Yes No
Medications Reason / Comments
Please check here, if you are taking more than five medications.
Have you had the following vaccinations? Yes No
Vaccination Date (Mo/Yr) Vaccination Date (Mo/Yr)
Are you allergic to or have had any adverse reaction to any drugs? Yes No
Medications Reaction / Comments
Please check here, if you are allergic to or have adverse reaction to more than five medications.
Have you had any surgeries? Yes No
Indication Findings Complications
Please check here, if you have had more than five surgeries.
Have you ever been diagnosed with HIV? Yes No
ENVIRONMENTAL FACTORS
If yes, how much? ________ (# of cigarettes/day)
If yes, how much? ________ (# of cigarettes/day) when did you quit? ________ (Mo/Yr)
If yes, how would you describe your drinking habits?
Alcoholic . _______ drinks / ________ (how often?)
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Do you have alcohol dependence? Yes No
Do you consume caffeinated beverages? Yes No
If yes, how much? 1-2 per day 3-4 per day More than 5 per day
Do you currently use "recreational" drugs? Yes No
If yes, what? ______________________________________
Do you use herbal remedies or medications? Yes No
Do you engage in long distance running or similar strenuous exercise? Yes No
If yes, how much (often) per week? ________
GENETIC / FAMILY HISTORY
Do you or anyone in your family have any of the following medical conditions? Yes No
Medical Condition
Mental Retardation - Chromosomal Testing
Mental Retardation - Testing for Fragile X Mutation
Chromosome Disorder (e.g. Down’s Syndrome)
Do you have a birth defect or familial disorder not listed above? Yes No
If yes, Please describe? _________________
What is your mother’s ancestry? _____________________________________
What is your father’s ancestry? _____________________________________
Have you or your significant other in this or any previous relationship had a stillborn child or more than two first trimester miscarriages? Yes No
Eastern European /Jewish Acestry
Have you had Tay Sach’s screening tests? Yes No
If yes, when? _______ (Mo/Yr). What were the findings? Normal Abnormal: _________________
Have you had a Canavan Screening Test? Yes No
If yes, when? _______ (Mo/Yr). What were the findings? Normal Abnormal: _________________
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Have you had Bloom Screening Test? Yes No
If yes, when? _______ (Mo/Yr). What were the findings? Normal Abnormal: _________________
Have you had Gaucher Screening Test? Yes No
If yes, when? _______ (Mo/Yr). What were the findings? Normal Abnormal: _________________
Have you had Fanconi Anemia Screening Test? Yes No
If yes, when? _______ (Mo/Yr). What were the findings? Normal Abnormal: _________________
Have you had Neimman-Pick Screening Test? Yes No
If yes, when? _______ (Mo/Yr). What were the findings? Normal Abnormal: _________________
African Ancestry
Have you had Sickle cell screening tests? Yes No
If yes, when? _______ (Mo/Yr). What were the findings? Normal Abnormal: _________________
European Ancestry or Family member with cystic fibrosis
Have you been tested for Cystic fibrosis? Yes No
If yes, when? _______ (Mo/Yr). What were the findings? Normal Abnormal: _________________
Italian, Greek, Mediterranean or Southeast Asian Ancestry
Have you had screening for inherited forms of anemia such as thalassemia? Yes No
If yes, when? _______ (Mo/Yr). What were the findings? Normal Abnormal: _________________
INFERTILITY TESTS
Have you had any of the following fertility tests in the past?
Ultrasound of the uterus and/or ovaries when NOT pregnant?
If yes, when? _______ (Mo/Yr). What were the findings? Normal Abnormal: _________________
Hysterosalpingogram (HSG)? An x-ray test of the uterus and tubes during which dye is injected into the uterus to “see” it
If yes, what were the findings? Normal uterus Abnormal uterus
Both tubes open One tube blocked Both tubes blocked
Hysterosonogram (also called sonohysterogram)? An ultrasound test in which saline (salt water is injected and an ultrasound is used to “see” the uterus.
If yes, what were the findings? Normal uterine cavity Abnormal uterine cavity: _________________
Laparoscopy? A telescope is placed through the belly button to see inside your abdomen Date (Mo/Yr) Indication Findings Complications
Please check here, if you have had more than three Laparoscopy tests.
Hysteroscopy? A telescope is placed through the vagina into the uterus in order to see the inside of the uterus. Date (Mo/Yr) Indication Findings Complications
Please check here, if you have had more than three Hysteroscopy tests.
Other tests to specifical y look at possible causes of infertility, miscarriage, or problems with menstrual cycle? Date (Mo/Yr) Female Information Powered by eIVF, a PracticeHwy.com product Date (Mo/Yr)
Chromosome Analysis (Karyotype) - Female
Chromosome Analysis (Karyotype) - Male Partner
PAST FERTILITY TREATMENTS
Have you ever had any Clomiphene citrate (Clomid, Serophene) cycle? Yes No
If yes, please list the last four (most recent) information below:
OHSS Birth Defect/ Abortion Miscarriage <20 wks
OHSS Birth Defect/ Abortion Miscarriage <20 wks
OHSS Birth Defect/ Abortion Miscarriage <20 wks
OHSS Birth Defect/ Abortion Miscarriage <20 wks
Please check here, if you have had more than four Clomiphene cycles.
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Have you ever had any Gonadotropins (Pergonal, Metrodin, Repronex, Humegon, Fertinex, Gonal-F, Follistim, Cetrotide, Antagon, Lupron) cycle? Yes No
If yes, please list the last three (most recent) Gonadotropin cyclesnformation below:
OHSS Birth Defect/ Abortion Miscarriage <20 wks
OHSS Birth Defect/ Abortion Miscarriage <20 wks
OHSS Birth Defect/ Abortion Miscarriage <20 wks
OHSS Birth Defect/ Abortion Miscarriage <20 wks
Please check here, if you have had more than four Gonadotropinscycles.
Have you ever had any In-Vitro Fertilization (IVF) cycle? Yes No
If yes, please list the last three (most recent) IVF cycles information below:
OHSS Birth Defect/ Abortion Miscarriage <20 wks
OHSS Birth Defect/ Abortion Miscarriage <20 wks
OHSS Birth Defect/ Abortion Miscarriage <20 wks
OHSS Birth Defect/ Abortion Miscarriage <20 wks
Please check here, if you have had more than four Gonadotropinscycles.
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Have you ever had any Frozen Embryo cycle? Yes No
If yes, please list the last three (most recent) Frozen Embryo cyclesinformation below:
Birth Defect/ Abortion Miscarriage <20 wks _
Birth Defect/ Abortion Miscarriage <20 wks _
Birth Defect/ Abortion Miscarriage <20 wks _
Birth Defect/ Abortion Miscarriage <20 wks _
Please check here, if you have had more than four Frozen Embryocycles.
Have you ever had any Gestational Surrogacy or Donor Egg Cycles? Yes No
If yes, what was the indication: ______________________________
Have you ever been an egg donor? Yes No
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Using Business Intelligence to Discover New Market OpportunitiesUsing Business Intelligenceto Discover New MarketOpportunitiesJanice FratesCalifornia State University Long BeachMany companies have customers of which theyBusiness Intelligence, Marketing, Competition,are only minimally aware, people who started using agiven product while seeking a solution for an appar-ently unrelated need. Th
European Journal of Anaesthesiology 2007; 24: 568–570r 2007 Copyright European Society of AnaesthesiologyGuidelines for anaesthesiologist specialist training in pain medicineSECTION AND BOARD OF ANAESTHESIOLOGY1, European Union of Medical SpecialistsWorking party on Pain Medicine: A. J. Cunningham*, J. T. A. Knapey, H. Adriaensenz, W. P. Blunniez,E. Buchsery, Z. GoldikJ, W. Ilias**, V. Paver-