*063U* University of Minnesota Physicians Reproductive Medicine Center 606 24th Ave S, Suite 500 Minneapolis, MN 55454 NEW PATIENT QUESTIONNAIRE Date questionnaire completed ______ / ______ / ______ Patient name ___________________________________ Last Date of Birth ______ / ______ / ______ Age ________ _______________________________ First Sex: Male Female ________________________ Middle Maiden Name _______________________ Address ____________________________________________________________ _____________ Street Apt. ___________________________________ ___________ __________________ ______________________ City State Zip Code County Marital Status: Single Married (date ______ / ______ / ______) Phone: (home) (______) _________________ OK to leave message? Preferred Contact number: Interpreter needed? Ethnic Origin: Home Yes Black White Yes No No Divorced Separated (work) (______) _________________ OK to leave message? Work Cell Yes OK to leave message? Yes No Language: ________________________________________________________________ Asian/Pacific Island Bi-Racial Hispanic American Indian Prefer not to answer Other ______________________________________________________ Occupation ____________________________________________ Pharmacy Phone (______) ________________ Employer _______________________________________ Insurance Provider ______________________________________________________ Infertility (cell) (______) _________________ No E-mail __________________________________________ Pharmacy Name __________________________________________________ Reason(s) for Visit: (check all that apply) Committed Relationship Inseminations Congenital anomaly In Vitro Fertilization Surgical Recurrent Miscarriages Referred by ________________________________________________ Referral needed? 2nd opinion Yes No Endocrinologic Problem Other _____________________ Phone (______) _________________ Primary Care Physician (PCP) ______________________________________________ Phone (______) _________________ Primary Ob-Gyn Physician ________________________________________________ Phone (______) _________________ With which physicians would you like information shared? Ob-Gyn Referring PCP Other _____________________________________________________________________________________ None Partner name __________________________________ _______________________________ ________________________ Last First Middle Partner’s Date of Birth ______ / ______ / ______ Age ________ Place of Birth __________________________________________ Partner’s Occupation ___________________________________________ Employer ________________________________________ Partner’s PCP ___________________________________________________________ 063U ASSESSMENT/QUESTIONNAIRE Phone (______) _________________ 03/2012 Page 1 of 11 CHIEF COMPLAINT (primary reason for coming to RMC) Infertility (Complete items below) Since when have you and your partner had intercourse without birth control? ______________________________ What, if any, was your last type of birth control? ______________________________ Number of prior marriages (not including current marriage if married) _____ No If yes, date of first infertility evaluation or treatment _____________ No If yes, specify _____________________________________ Other chief complaint (please specify) ________________________________________________________________________ PREVIOUS PREGNANCY DATA Please list all pregnancies, first to last, including miscarriages, abortions, and tubal pregnancies; if none, check here With current partner? 1 Yes No 2 Yes No 3 Yes No 4 Yes No 5 Yes No 6 Yes No 7 Yes No 8 Yes No Date pregnancy delivered or ended Length of time to conceive Infertility treatment required? (specify) Duration of pregnancy Outcome & details* *Indicate: (1) whether pregnancy resulted in live birth (provide birth weight & sex of child), stillbirth, miscarriage with or without completion procedure (D&C), biochemical pregnancy, elective termination (abortion), or tubal pregnancy; (2) mode of delivery (e.g., vaginal delivery or cesarean section); (3) if pregnancy was a twin or other multiple pregnancy; (4) duration of breastfeeding after delivery Were any of your pregnancies or deliveries associated with medical problems (such as gestational diabetes, infection, need for blood transfusion)? Yes No If yes, please briefly describe below _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ MENSTRUAL CYCLE & RELATED HISTORY Age at first period ______ What were your periods like as a teenager? _______________________________________________ First day of last period _____________ First day of period before that _____________ Describe your cycles when not taking medications that affect them (such as birth control pills or fertility drugs): Regularity: regular Usual volume of flow: slightly irregular light normal very irregular absent Usual range of days from one cycle to next __________ heavy Describe any unusual aspects of flow ______________________________ How many days do your periods last? __________ Cramping/pain with periods: U063 ASSESSMENT/QUESTIONNAIRE none mild moderate severe 01/2011 Page 2 of 11 Describe days when cramping/pain occurs (including premenstrual) ___________________________________________________ Medications used & doses and duration for menstrual symptoms ___________________________________________________ Spotting between or before periods? Yes No If yes, describe ________________________________________________ Do you consider your menses to be abnormal? Yes No If yes, why? _________________________________________ Any premenstrual symptoms (e.g., breast symptoms or mood changes)? Have your periods changed over the last year? Yes No Yes No If yes, describe ___________________ If yes, describe _________________________________________ Have you done basal body temperature charting or used ovulation detection kits? Yes No If yes, describe results below _________________________________________________________________________________________________________ Any recent use of hormonal medications that could affect your cycles, such as birth control pills, Provera, Lupron, or fertility drugs? Yes No If yes, describe _____________________________________________________________________________ Have you ever used birth control pills to make your cycles regular? Yes No Have you ever taken Provera, Prometrium, or similar drugs to bring on a period? Has your weight changed significantly over time? Yes Yes No No If yes, describe _______________________________________ Highest non-pregnant weight ______ lbs (when? __________ ) Lowest adult weight ______ lbs (when? ___________ ) Briefly describe average weekly exercise ________________________________________________________________________ Indicate if you have had or been told that you have any of the following, and if so, briefly describe, including treatment measures: Acne/oily skin ________________________________________________________________________________________ Abnormal hair growth __________________________________________________________________________________ Frontal or other hair loss ________________________________________________________________________________ Milk or other breast discharge not related to pregnancy ________________________________________________________ Hot flashes or night sweats ______________________________________________________________________________ Polycystic ovarian syndrome ____________________________________________________________________________ Premature ovarian failure/menopause or primary ovarian insufficiency ___________________________________________ Diminished ovarian reserve ______________________________________________________________________________ Diabetes, thyroid disease, or high prolactin level _____________________________________________________________ Have you had any hormone testing done (e.g., FSH levels, thyroid testing, male hormone levels)? If yes, describe any results that you know about below Yes No _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ How many times per week on average do you and your partner have intercourse? _______________________________________ Do you have pain with intercourse? Yes No If yes, describe __________________________________________________ Do you use lubricants with, or douche before or after intercourse? Do you attempt to “time” intercourse? U063 Yes No Yes No If yes, describe __________________________ If yes, how? __________________________________________________ ASSESSMENT/QUESTIONNAIRE 01/2011 Page 3 of 11 FEMALE INFERTILITY: HISTORY, TESTING, & TREATMENT (please complete as appropriate even if not infertile) Anatomic problems (tubal disease, uterine/cervical problems, scar tissue, endometriosis, etc.) Have you ever been hospitalized or had a pelvic infection such as pelvic inflammatory disease (PID) or endometritis? Yes No If yes, describe _____________________________________________________________________________ Have you ever had unexplained abdominal or pelvic pain? Yes No If yes, describe _____________________________________________________________________________ Have you had or been treated for any of the following sexually transmitted diseases? HIV/AIDS Genital warts/HPV Genital herpes Hepatitis B or C Chlamydia Gonorrhea Syphilis Other (specify) _______________________ Have you ever been told that you have blocked tubes or pelvic adhesions (scar tissue)? Yes No If yes, describe ______________________________________________________________________________ Please indicate if you have had any of the following conditions, and if so, briefly describe, including surgery or other treatment measures: Congenital uterine or kidney abnormality ___________________________________________________________________ Uterine myomas (fibroids) _______________________________________________________________________________ Uterine or cervical polyps _______________________________________________________________________________ Endometriosis ________________________________________________________________________________________ Ovarian cyst(s) or tumor(s) ______________________________________________________________________________ Appendicitis, with or without rupture _______________________________________________________________________ Please indicate if you have had any of the following tests or procedures, and if so, briefly describe, including dates, findings, and other pertinent details: Post-coital testing (test assessing sperm in cervical mucus after intercourse) _______________________________________ Hysterosalpingogram (HSG) ____________________________________________________________________________ Pelvic ultrasound study _________________________________________________________________________________ Sonohysterogram _____________________________________________________________________________________ Endometrial biopsy ____________________________________________________________________________________ Laparoscopy _________________________________________________________________________________________ Hysteroscopy _________________________________________________________________________________________ D&C ________________________________________________________________________________________________ Laparotomy __________________________________________________________________________________________ Surgeries on cervix for abnormal Pap smears (e.g., LEEP or cone biopsy) _________________________________________ Surgery to place a cervical cerclage (for “cervical incompetence”) ________________________________________________ Sterilization procedures or reversals _______________________________________________________________________ U063 ASSESSMENT/QUESTIONNAIRE 01/2011 Page 4 of 11 Treatment measures (including for ovulation problems, unexplained infertility, etc.) Have you ever been treated with clomiphene citrate (Clomid) or letrozole (Femara)? Yes No If yes, briefly describe, including dates, number of cycles with and without inseminations (IUIs), use of ultrasound and hormone tests to monitor response, whether hCG (or Ovidrel) injections were used to trigger ovulation, side effects/adverse reactions, names of managing physicians/fertility centers _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Have you ever been treated with injectable FSH drugs (such as Bravelle, Gonal-f, Follistim, Menopur, Repronex) in treatment cycles not involving in vitro fertilization (IVF)? Yes No If yes, briefly describe, including dates, number of cycles with and without inseminations (IUIs), use of other medications during such cycles (such as progesterone), side effects/adverse reactions, names of managing physicians/fertility centers _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Have you ever undergone IVF treatment? Yes No If yes, briefly describe, including dates, number of fresh cycles, number of frozen embryo cycles, outcomes, names of managing physicians/fertility centers _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Have you undergone any treatment not mentioned above, to either become pregnant or maintain a pregnancy, such as undergoing inseminations or IUIs (including with donor sperm), using a progesterone supplement after ovulation (such as suppositories or Prometrium), or using baby aspirin or heparin? Yes No If yes, briefly describe _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ OTHER GYN & RELATED HISTORY When your mother was pregnant with you, did she take DES or a related drug to prevent miscarriage? Past birth control measures: Diaphragm Condoms Birth control pills Depo-Provera Sterilization (female/male) Yes No Unsure Other hormonal (eg, NuvaRing, Ortho Evra patch) IUD Rhythm, partner withdrawal, other (specify) ________________ Please describe any problems you had with any of the above ______________________________________________________ Have you had an abnormal Pap smear? Yes No Have you had any of the following vaginal infections? If yes, describe any related procedures or testing ___________________ Yeast/candida Bacterial vaginosis Trichomoniasis Other If you have, briefly describe ________________________________________________________________________________ U063 ASSESSMENT/QUESTIONNAIRE 01/2011 Page 5 of 11 If you have had any gyn problems or surgeries not already mentioned, please describe ___________________________________ Have you had frequent bladder or urinary tract infections? Yes No If yes, please describe _______________________ Any breast problems (such as fibrocystic disease), surgeries, biopsies, or other tests? Yes No If yes, please describe: _________________________________________________________________________________________________________ OTHER MEDICAL, SURGICAL, & RELATED HISTORY Current medications & supplements (include prescription & over-the-counter, herbal, vitamin & other supplements): __________________________________ __________________________________ ________________________________ __________________________________ __________________________________ ________________________________ __________________________________ __________________________________ ________________________________ Any allergies or adverse reactions to medications? Yes No If yes, please list and describe reaction (eg, rash, nausea/ vomiting) _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Any environmental or food (peanut, eggs, shellfish, etc.) allergies or latex allergy/sensitivity? Yes No If yes, briefly describe _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Any concerns about toxic exposures? Any special diets or dietary restrictions? Yes No Yes No If yes, please describe __________________________________________ If yes, please describe ________________________________________ Please briefly list any surgeries not already described, with dates and any complications (eg, anesthesia or bleeding problems) _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Please describe any hospitalizations or significant medical illnesses not described above _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Did you have chickenpox as a child? Yes No Unsure Have you had the rubella (MMR) vaccine or had German measles? If no, have you had the varicella vaccine? Yes No Yes No Unsure Blood type if known ________ (lab documentation required) If Rh-negative, did you receive Rhogam at the time of your pregnancies? Yes No Unsure If any genetic testing (e.g., for cystic fibrosis or Tay-Sachs disease), please describe _____________________________________ U063 ASSESSMENT/QUESTIONNAIRE 01/2011 Page 6 of 11 If not already described, please indicate if you have had any of the following: General Unexplained weight gain/loss Unexplained fevers or night sweats Unexplained fatigue Enlarged lymph nodes Cardiovascular High blood pressure Palpitations/skipped heart beats Scarlet fever or rheumatic fever Mitral valve prolapse Other congenital heart valve disease Coronary artery disease Other heart or vascular disease Gastrointestinal Ulcers Esophageal reflux (GERD or heartburn) Ulcerative colitis or Crohn’s disease Celiac disease (sprue) Hepatitis or other liver problems Gallbladder problems Lactose intolerance Irritable bowel syndrome Unusual diarrhea Unusual constipation Blood in stool Other gastrointestinal disease or symptoms Genito-Urinary Kidney disease Hematuria (blood in the urine) Other genitor-urinary disease Head, Ears, Eyes, Nose, & Throat Deafness or hearing loss Tinnitus (ringing in ears) Unexplained visual symptoms Lack of sense of smell Other problem Hematologic Anemia -- if checked, indicate cause if Known ( e.g., iron deficiency) __________________________________ Blood transfusion Sickle cell disease or trait Thalassemia or related condition von Willebrand disease Venous thromboembolism (e.g., blood clot in leg) G6PD deficiency Tendency to bruise or bleed easily Other blood problem Mental Health Problems Attention deficit hyperactivity disorder ( ADD) Obsessive-compulsive disorder (OCD) Other anxiety disorder or symptoms Depression Schizophrenia Other psychiatric/psychological problem Musculoskeletal Fibromylagia Systemic lupus erythematosus (SLE or lupus) Rheumatoid arthritis Other arthritis Carpal tunnel syndrome Other musculoskeletal problem Neurologic Migraine or other vascular headaches Epilepsy or seizure disorder Cerebrovascular accident (stroke) Memory loss Unexplained weakness or loss of balance Other neurologic problem Pulmonary/Respiratory Asthma Tuberculosis or positive PPD test Pneumonia Sleep apnea Bloody cough Other throat/lung disease Skin Eczema Skin cancer Psoriasis Moles changing in appearance Significant burn injury Unexplained rash Other skin problem Smoking/tobacco history: Never or essentially never smoked cigarettes Ex-smoker: Previously smoked ___ cigarettes per day for ___ years, but quit _________ Current smoker: Currently smoke ___ cigarettes per day, and have smoked for ___ years Other (specify) ________________________________________________________________________________________ Alcohol consumption: Never or essentially never consumed alcohol Previously consumed alcohol, but not currently Currently consume alcohol, with average of ___ drinks per week Other habits: Current caffeine consumption: average ___ number of coffee cups/equivalents per day Current or past recreational drug use? Yes No If yes, please describe _______________________________________ Have you ever been in treatment program for discontinuing or limiting the use of drugs or alcohol? U063 ASSESSMENT/QUESTIONNAIRE Yes No 01/2011 Page 7 of 11 EMOTIONAL STATUS Have you ever experienced sexual or physical abuse as an adult or child? Yes No On a scale of 1-10 (10 being worst), estimate the level of stress you feel due to infertility _________ Briefly describe any emotional, marital, or sexual problems due to you infertility __________________________________________ Do you see a counselor? Yes If no, would you like to see one? No Yes If yes, since when, and how often? ___________________________________________ No FAMILY/GENETIC HISTORY Mother: Alive, now age ________ Deceased at age ________ Age at menopause ________ Ancestry (countries of origin/ethnicity of ancestors)_______________________________________________________________ Health problems? (describe) ________________________________________________________________________________ Father: Alive, now age ________ Deceased at age ________ Ancestry _______________________________________ Health problems? (describe) ________________________________________________________________________________ Number of sisters _____ Health/infertility problems? (describe) _____________________________________________________ Number of brothers _____ Health/infertility problems? (describe) ____________________________________________________ If you have children, describe any health problems _________________________________________________________________ Is there any family history of the following? We are primarily interested in first degree relatives (e.g., parent or sibling) and second degree relatives (e.g., aunt or grandparent), but also third degree relatives (e.g., first cousin) for conditions such as cystic fibrosis that are essentially entirely on a genetic basis. Autoimmune disease Psoriasis Rheumatoid arthritis Scleroderma Systemic lupus erythematosus (SLE or lupus) Other autoimmune disease Hematologic Anemia -- if checked, indicate cause if Known ( e.g., iron deficiency) Sickle cell disease or trait Thalassemia or related condition von Willebrand disease Venous thromboembolism (e.g., blood clot in leg) -- if known genetic predisposition (e.g., factor V Leiden mutation), indicate below G6PD deficiency Tendency to bruise or bleed easily Other blood problem Cancer Breast Colon Endometrial (uterine) Ovarian Prostate Other cancer (Known) Genetic Disease (including family members without disease but thought to be carriers) Cystic fibrosis Muscular dystrophy Other – specify below Hormonal Disorders Diabetes -- if known, indicate if diabetes is type 1 (early-onset) or type 2 (late-onset) Thyroid disorders Other hormonal disorder Mental Health Problems Depression Schizophrenia Substance abuse Other Miscellaneous Birth defect Stillbirth Mental retardation Early heart disease Neurologic disorder Reproduction-Related Infertility Recurrent miscarriages (> 2) Polycystic ovarian syndrome Early menopause Endometriosis Uterine myomas (fibroids) Twins, triplets, etc. For checked items, briefly describe (e.g., “sister had 4 miscarriages; 2 paternal aunts had breast cancer; two maternal first cousins have cystic fibrosis; both maternal grandparents had type 2 diabetes”) _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ U063 ASSESSMENT/QUESTIONNAIRE 01/2011 Page 8 of 11 MALE PARTNER HISTORY Number of prior marriages (not including current if married) _____ Number of pregnancies conceived with prior partners _____ Did you have any children with prior partners? If yes, provide years of birth _____________________________________________ If any, briefly describe infertility history with prior partners ___________________________________________________________ Have you previously had a semen analysis? If yes, if known provide results below Date Location Concentration (number of sperm per mL) Volume (mL) Motility (% with progressive motility) Morphology (% with normal forms) Other Have you had or do you anticipate difficulty collecting a semen specimen in an office of clinic? Yes No Have you been evaluated by a urologist? Yes No If yes, please indicate name, address, and phone number below _________________________________________________________________________________________________________ Have you ever been told that that there were any genital abnormalities on physical exam (such as a varicocele)? Yes No If yes, describe __________________________________________________________________________________________ Have you had testing done related to infertility besides a semen analysis (e.g., such as an ultrasound study, hormone studies, or genetic testing)? Yes No If yes, describe any results that you know about below _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Have you had or been treated for any of the following sexually transmitted diseases? HIV/AIDS Genital warts/HPV Genital herpes Please indicate if you have had any of the following: Recurrent urinary tract infections Hernia surgery Erectile dysfunction Hepatitis B or C Undescended testis Mumps after puberty Urethral dilatation Chlamydia Syphilis Other (specify) _______________________ Testicular injury or swelling Any hormonal disorder Prostatitis Chemotherapy or radiation for cancer Testosterone treatment or use of anabolic steroids Ejaculation problems Gonorrhea Blood in the ejaculate Decreased libido or sex drive Please describe any checked items __________________________________________________________________________ Have you had a fever in the last 3 months? Yes No If yes, describe ___________________________________________ Describe any exposure to prolonged heat, radiation, or harmful chemicals in your workplace ________________________________ Do you use hot tubs or steam baths? Yes No If yes, describe ________________________________________________ Current medications & supplements (include prescription & over-the-counter, herbal, vitamin & other supplements): __________________________________ __________________________________ ________________________________ __________________________________ __________________________________ ________________________________ U063 ASSESSMENT/QUESTIONNAIRE 01/2011 Page 9 of 11 Any allergies or adverse reactions to medications? nausea/vomiting) Yes No If yes, please list and describe reaction (e.g., rash, _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Please describe any surgeries, hospitalizations, or significant medical illnesses not described above _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ If any genetic testing (e.g., for cystic fibrosis or Tay-Sachs disease), please describe _____________________________________ Smoking/tobacco history: Never or essentially never smoked cigarettes Ex-smoker: Previously smoked ___ cigarettes per day for ___ years, but quit _________ Current smoker: Currently smoke ___ cigarettes per day, and have smoked for ___ years Other (specify) ________________________________________________________________________________________ Alcohol consumption: Never or essentially never consumed alcohol Previously consumed alcohol, but not currently Currently consume alcohol, with average of ___ drinks per week Other habits: Current caffeine consumption: average ___ number of coffee cups/equivalents per day Current or past recreational drug use? Yes No If yes, please describe _______________________________________ Have you ever been in treatment program for discontinuing or limiting the use of drugs or alcohol? Yes No MALE FAMILY/GENETIC HISTORY Mother: Alive, now age ________ Deceased at age ________ Ancestry (countries of origin/ethnicity of ancestors)_______________________________________________________________ Health problems? (describe) ________________________________________________________________________________ Father: Alive, now age ________ Deceased at age ________ Ancestry _______________________________________ Health problems? (describe) ________________________________________________________________________________ Number of sisters _____ Number of brothers _____ Health/infertility problems? (describe) _____________________________________________________ Health/infertility problems? (describe) ____________________________________________________ If you have children, describe any health problems _________________________________________________________________ U063 ASSESSMENT/QUESTIONNAIRE 01/2011 Page 10 of 11 Is there any family history of the following? Cancer Breast Ovarian Prostate Other cancer We are primarily interested in first degree relatives (e.g., parent or sibling) and second degree relatives (e.g., aunt or grandparent), but also third degree relatives (eg, first cousin) for conditions such as cystic fibrosis that are essentially entirely on a genetic basis. Hematologic Anemia -- if checked, indicate cause if known ( e.g., iron deficiency) Sickle cell disease or trait Thalassemia or related condition Other blood problem (Known) Genetic Disease (including family members without disease but thought to be carriers) Cystic fibrosis Muscular dystrophy Other – specify below Hormonal Disorders Diabetes -- if known, indicate if type 1 (early-onset) or type 2 (late-onset) Thyroid disorders Mental Health Problems Depression Schizophrenia Substance abuse Other Miscellaneous Birth defect Stillbirth Mental retardation Early heart disease Neurologic disorder Reproduction-Related Infertility Recurrent miscarriages (> 2) For checked items, briefly describe (e.g., “sister had 4 miscarriages; 2 paternal aunts had breast cancer; two maternal first cousins have cystic fibrosis; both maternal grandparents had type 2 diabetes”) _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ U063 ASSESSMENT/QUESTIONNAIRE 01/2011 Page 11 of 11