606 24 Ave S, Suite 500 Minneapolis, MN 55454

*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?
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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 _______________________________________________________________________
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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 ________________________________________________________________________________
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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 _____________________________________
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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”)
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
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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):
__________________________________
__________________________________
________________________________
__________________________________
__________________________________
________________________________
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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 _________________________________________________________________
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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”)
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
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ASSESSMENT/QUESTIONNAIRE
01/2011
Page 11 of 11