AmerICAN Society FOR REPRODUCTIVE MEDICINE Infertility History Form IMPORTANT: Please complete this form and bring it with you to your scheduled visit. This form was developed by the American Society for Reproductive Medicine to assist physicians and patients in obtaining a complete infertility history. It consists of three parts: Part: Contact information Parti: Your medical history Pat Ill: Your spouse/male partner's medical history (if applicable) PART I: CONTACT INFORMATION FOR OFFICE USE ONLY First Name Middle Initial __ Last Name Date of Bith(MMIDDIVY)_—/_/. Oceupation Home Street Addicts cay Stete__ Zip/Postal Code Couy Indicete which munber to call or leave messages. ClHome Telephone ( ), (Cl Work Telephone ( Call Phone ( Ase youmanied Yes ONo (Divorced Oi Other ‘Spouse/Partner's First Name ‘Middle Initial _ Last Name (Not Applicable Date of Bith (MM/DD/YY) Occupation, Home Street Addcess city, State ZiplPostel Code County. Indicete which manber to call or eave messages. ClHome Telephone (), Cl Work Telephone ( Call Phone ( Whe referzed you? Physician Physician Notes Name Phone ) {for office use only) Addvess Former Petient/Friend, website Ci Inswence (ame of Fnmwence), Whe is your Ob/Gyn? Name Phone ( ) Addvess ‘Whe is your Primary Care Physician? Name Phone ( ) Addvess Page +PART Il: FEMALE MEDICAL HISTORY AND INFORMATION Reason for Visit: Ci Infertility Evalustion O Insemination O Other ‘What are your expectations for this visit ‘What questions de want answered at this Do you have any personal, ethical, or religious objections to any of ous tests or treatments such as insemination, in vitro fertilize. tion, ¢gg donation, sperm donation, masturbation to collect @ semen sample, ete.” 0 Yes ONo How many months have you been having intercourse without using any form of bisth control? Pregnancy Summary + Total Number of ALL Pregnancies: + Number of Miscassiages (less than 20 weeks): + Number of Ectopic/Tubel Pregnancies «+ Number of Elective Terminations (Abertions) + Number of Full exm Deliveries (Ofthece, howe many vere live births? __ How many ware stilbom? + Number of Premature (lees than 37 weeks Deliveries: Of there, how many were live bit? ___ How many were stilbom? __ + Any Pregnancies with Birth Defects? D Yes- explain’ Date Pregnancy Months to ‘Treatments to Delivery Type D&C] Ended or Delivered Conception Conceive Complications 1 3 4. 5. 6 Menstrual History + Menstrual eyele pattem (check all that apply): Cl Regular periods Cl Invegular periods O Spotting before pesiods 0 No periods ClHeavy periods CLight periods Ol Bleeding between periods + Number of days between the start of one period the start of the next period ___days + How many days of bleeding do you have? ___days «Dates of the lst day of your last 2 menstrual periods a) + Age when you had yous first period’ ___years old + Age when youfirst noticed Breast development _ years old Pubic hair’ __yeare old Undermm heir’ __yeaus old + How many periods do you have per year? + Do youneed medication to bring on a period? Di Yes - what type? ONo + If you do not have periods, at whet age did you stop having them? years old + Do youhave severe cramping or pelvic pain with your periods? © Yes _Abrays _Somatimes_Recenfly Inthe past No + Did your mother take DES (en estrogen derivative) when she was pregnant with you? @Yes No Don't now Contraceptive History DNone CO Condoms - detes of use C Diephegm - dates of use CFosm of Jelly CBisth contol pills - detes of use complications? Never used bsth conteol pills CD injectable contraception Depo Provere®, LimelleM!, ete) - dates of we onplications? Skin pateh- dates of use ~ complications? IUD dates of use Tubal sterilization procedure (Ribes ted) - dete (monthlyens)_——7 Ti Tibes untied date (monthiyess) 7 Sexual History + Are you sexually sctive? Yes ONo Isyow partner 0 Mele O Female + How many times do you have intercourse per week? times per week None (i Not applicable + Have you used over-the-counter ovulation kits to time intercourse? Yes No + Do youhave pain with intercourse? B Yes QNo + Do you use lubricants (K-Y Jelly®, Astroglide® etc) during intercourse? LI Yes - whet types? ONo + Have you had any of the following sexuelly transmitted diseases or pelvic infections? OI Yes check all that apply) No OChemydie date Gonorrhea - dete, Ci Herpes. date Ci Genital wasts/HPV - date Syphilis - date, CO HIV/AIDS - date Ci Hepatitis - date Other - date, Page?Pap Smear History + When was yous lest pap sneer (month and yea)?__/ CNomel CO Abnormal + When was yous lest abnormal pap seas? CINot applicable Have you undergone any procedures as a sesult of en ebnormal pep smea:? (Yes (check all that epply) No Colposcopy OCryonxgery Freezing) CLasertreatment CConizstion OLEEP procedwe Breast Screening History Have you ever had a mammogram? Oi Yes date Result C normal 0 abnormal - explain ONo Do you perfom treast self exams? QYes ONo Medical History + Ave you allergic to any medications? O Yes ONo If yes, please list and describe reactions + Are you allergic to any foods (peanuts, eggs, ete)? Yes No If yes, please list and describe reactions + List eny medicstions you are curently teking including over-the-counter medicines + Do youtake any herbal medicines/vitamins or health food store supplements? OYes ONo Ifyes please list + Do youhave any medical problem(s)? Cl Yes Please list type, dates, and treatments) O1No Surgical History + Have you had any axgeries? (i Yes (List all sugeries in chronologic order) No Year Reason and Type of Sugery oO ©, Qo 2 eo ®, oo o oOo o, Oo ©. OO ®. + Did you have any problems with anesthesia? O Yes (desesibe ) ONo + Have you had either of these childhood illnesses? Cl Chickenpor (Varicelle) (German Measles Rubelld) 1 Don't know Other childhood diseases Vaccinations + BCG (Tuberculosis) O Yes (dates ) No ODen'tknow + Chickenpox (Varicele) 1D Yes (dates } No ODen't know + Hepatitis A. 1D Yes (dates } No ODen't know + Hepatitis B 1D Yes (dates } No ODen't know + Influence: 1D Yes (dates } No ODen't know + MMR - Measles Mumps, and Rubella (German Measles: O Yes (dates } No ODen't know + Pertussis (Tdap_) 1D Yes (dates } No ODen't know + Polio 1D Yes (dates } No ODen't know + Tetanus 1D Yes (dates } No Don't know PagesSocial History + How many caffeinated beverages (coffee, tee, soda) do you drink per day/? None + Do you smoke cigaettes? O Yes How menylday?, How many yeaid? O Quit- when? ONo + Do you drink alcohol? Yes o® many drinks per week? _ + Have you casually used marijuana, cocaine, or any other smile drug? Ol Yes (describe Ne + Doyou exercise? Oi Yes (describe )ONo + Ave you aware of eny radiation expomices other then X-ays? Oi Yes (descsibe, No + Do youfeel safe in your own home? Yes (describe ) No Review of Physical Symptoms General: Head, Eyes, Ears, Nose, and Throat: Respiratory: Recent weight gain or loss Dizziness Ch Loss of sense of smell Ci Shortness of breath, CAnorexie’ ulimie Headaches © Cluonie nasal congestion DAsthma Bronchitis Lack of energy (CD Bluzed vision O Ringing ears DPaeumonia Ol Tuberculosis D Feves/Challs Heating loss/deafness Bloody cough Other Other Other None None None Endocrine/Hormonal: Breasts: Neurological Problems: Diabetes CO Heir lose (i Discharge (clea/?__ bloody?__ milky?__) 0 Weskness/Loss of balance D Thyroid gland problems DLunps Pan OCencer D SeizweslEpilepsy D Repid weight gain of loss CD Abnormal mammogram C Headaches Di Excessive ungerfthicst CD Reduction CD Migraine heedaches i Temperatuce intolerance Augnentation/Breast implants CD Numbness hot flashes or feeling cold (ealine?___ silicone?__) CD Memory loss Other Other Other None None None Gastrointestinal: Genito-Urinary: Skin/Extremities: Neuse omiting Ulcers (Ci Bledder infections 1 Unexplained rashvinflemmetion D Hepatitis DDiewhes Kidney infections DAcae Bloodin yow stools OConsipation O Vaginal infections (Skin cancer Di Initeble Bowel Syndrome (Frequent winetion Oi Leaking wine DBuainwy Change in bowel habits (Blood in the wsine CD Moles changing in appearance i Colitis (ulcerative ar Crohn's) DHapes CD Excess heir growth, Other Other Other None None None ‘Musculoskeletal: Hematologic: Cantiovascular: 1D Unusual muscle weakness (D Blood dloting disarde/Blood clot Palpitations! kipped beats 1 Decreased enexgy/stemina Sickle cell Anemia Ci Thrombophlebitis (Chest pain CO Heat attack D Rheumatoid arthitis DD Easy bruising D Stroke D Mums Lupus Erythematosus CD Myasthenia gravis Other None ‘Mental Health Problems: Depression O Anstiety disorder D Schizophrenie Other None CD Swollen glendslymph nodes 1D Blood transfusions (testersans Other None 1 High blood presse D Rheumatic fever ( Mitral valve prolapse @tedaehines ‘face nel procedres? Vis_No_ Other None Physician Notes (for office use only) PagesFamily History Living Cause of Death/Age at Death other Yes age__ ONo + Father DYes- age ONo + Brothex(3) DYes- age ONo DYes- age ONo + Sister(s) DYes- age ONo DYes- age ONo + Matemal Grandmother OYes- age No + Matemal Grandfather OYes- age No + Paternal Grandmother OYes- age ONo «Paternal Grandfather OYes- age ONo Medical or Genetic Disorders in YowYour Family Self or Relationship to You «Baby withbirthdefect Yes + Buth defects OYes Blood clots Des ‘Bloom syniiome Yes + BoneSleletal Defects Yes + Cenmvan disease OYes * Cancer Des + Breast cancer OYes + Colon cancer OYes + Oranan cancer OYes * Other cancer Des + Color Blnnaae OYes + Cystic Fhroms OYes +Deafess/Blininess Yes «Developmental delay Yes + Diabetes Yes + Down syndrome Yes + Other chromosome defects Yes + Dwaafism Yes + Endometriosis Yes + EpilepeySeizue disorder OYes «Familial yeutonia Yes + Fanconi Anemia, Yes + Fragile X Yes + Galactosemia Yes + Gallstones Yes + Gaucher disease Yes + Glaucoma Yes + Heart defect fiom bith Yes, + Heart disease Yes + Hemochromatosis Yes + Hemophilia Yes + Hepatitis Yes + High blood presswe Yes + High cholesterol Yes Hormonal disorder Yes. +HuntingtonChora Yes + Hydrocephalus Yes + Infestlity Yes ‘ Inhenited disorder Yes «Leeming problems Yes. + Manfan syndrome Yes + Menopause before age 40. Yes + Miscamiages (2 or more) CYes + Muscular ystiophy Yes + Myotonic ystophy Yes +Newal ube efects CVes +Newofibromatosis Yes + Newologic (orainfspine) Yes No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No Don’t Know (Don’t Know (Don’t Know Don’t Know (Don’t Know (Don’t Know (Don’t Know Don’t Know (Don’t Know (Don’t Know (Don’t Know Don’t Know (Don’t Know (Don’t Know (Don’t Know Don’t Know (Don’t Know (Don’t Know (Don’t Know Don’t Know (Don’t Know Don’t Know (Don’t Know Don’t Know (Don’t Know (Don’t Know (Don’t Know Don’t Know (Don’t Know (Don’t Know (Don’t Know Don’t Know (Don’t Know (Don’t Know (Don’t Know (Don’t Know Don't Know (Don’t Know (Don’t Know Don’t Know (Don’t Know (Don’t Know (Don’t Know (Don’t Know (Don’t Know (Don’t Know (Don’t Know Don’t Know (Don’t Know What is your Ancestry? American Indian or Alasen Native DAs Hawaii n Native or other Pacific Idender Black, not of Hispanic Origin O Hispanic C1 White, not of Hispanic Origin O Mixed sace Dotter (pecify ) Pages+ Niemann Pick disease Yes No Don't Know + Obesity es No Don't Know + Polyeytic Kidney disease Bes No Don't tow + Psychiat problems Byes No Don't tow + Renal disease Bes No Don't Know + Sickle ell nemia Dyes No Don't Know Spinal useular ttophy(SMA) Yes No Don't frow + TaySechs disease Yes No Don't tow + Thalassemia Byes No Don't tow ‘Thyroid problems es No Don't Know + Thbercuosis Byes No Don't tow CNone of the above Other (Specify, GENETIC SCREENING Itis recommended that all couples attempting conception be offered cystic fibrosis screening. Cystic fibrosis is a pulmonary disease affecting children and the most common genetic disease. The effectiveness of the test varies depend "on your ethnic background. You may be offered additional screening based on your ethnic ty. Are you: African American OYes GNo Ashkenazi Jewish GYes GNo Mediterranean/Asian/French Canadian GYes GNo If you answered YES to any of these, please let your physician know at the visit, so that the additional genetic screening can be offered to you. If you have any specific genetic concerns and desire to see a geneticist, please let the physician know. PRIOR INFERTILITY TESTING AND TREATMENT + Have you had prior infestilty testing or treatment elsewhere? OYes No Prior Tests (check all thet apply): O Basal body temperatuce chest (date__/esulte CO Thyroid test (dete__fesulte (CTOvulation teat kat (date___enilts, i Day 3 blood test for FSH level (date__fesults } GHysterosslpingogam HSG) (dete__frealte Laparoscopy sugery (date__/results CHysteroscopy smgery (date__rewults > (Progesterone blood test (date__ results, (Prolactin blood test (date___esults > Prior Treatment (check all that apply) |—Pregnant: _Deineed rp _Mscomng: Not Pregrant Pregnant: Detnend Bp _Micerag. Not Pregnant (CD Intrastesine incemsination: [D Clomuphene itae with timed infereouze smaxinaim # tablet: per day” (Clomiphene ciate vith invention smaxinaim # tablet per day” (Daily ferlity dug injections Wi ivemsination: rmaxizaum #vials per day? (Ci Completed in vito fertlioaion eyelet 1 eggs Hembryes tarsfemed__ Miiozen__ 2. egg: Hembryes tarcfemed__ Hiiozen 3. Heggs__ Henbryo: tarsfened__ #iozen 4. Heggs__ Henbryo: tarsfened__ #fiozen (CO Fiopen embryo travfer: 1 #embryes tancfered 2. Hembryes tansfened 3 Henbnyos tafened 4 Henbryos taefened (CCancelad in vino fertilization attempt) |Pregnant: _Deineed pi _Mscong: Not Pregant J Pregnant: _Delnmed_upc _scerag: Not Pregnant Pregnant: _Deineed Eni _Nscmag: _NotPregrant “Pregnant: Delneed Enop —Mscmag: —NotPregrant Pregnant: Deineed Erp _Mscmag. —NotPregrant “Pregnant: DeineedEnopi —Mscenagg: —NotPregrant Pregnant: _Deineed Bap _Nscmig: _NotPregrant Pregnant: Deineed Bop _Mscmig.: Not Pregrant “Pregnant: “Deineed Brae —Mscenig: Not Pregrant Pregnant: Deineed np _Nscmag. —NotPregrant Cl Any other prior treatment (describe) + Additional Information/C omplicetions PageeEMOTIONAL STATUS + Ona scale of 1-10 (10 being the wors), estimate the level of stress you feel due to infertility and other pressures + Do you see a counselox? Di Yes- Fer how long? How often? + List eny antidepressant/antianciety medications you are curenlly taking + Describe any emotional, marital, or sexual problems caused by your infertility ONo PATIENT'S SIGNATURE DATE. I confirm that I have reviewed the information above. PHYSICIAN'S SIGNATURE, DATE. PART Ill: MALE MEDICAL HISTORY AND INFORMATION ‘Complete with your male partner if applicable. + Have you been evalusted by a wologist?” O Yee No + Have you previously conceived with another women? C1 Yes How many timed? (No Birth control used? + Have you had e semen analysis? Yes ONo Date ‘Volume Count Motility Mexpholegy + Do you have difficulty with erections? O Yer No + Ave you able to ejaculate inside your partner's vagina? OYes No + Do youhave retrograde ejaculation of spesm into the bladder? O Yes No + Have you had any of the following sexually transmitted diseases or severe testicular pain? (Yes (check all thet apply) O No CO Chlemydie- date Ci Gonorshen- date Herpes date Genital wartsHPV - date Ci Syphilis - date CHIVAIDS - date Hepatitis date Other + Have you had « history of undescended testicles? C1 Yer-One side__Both_ No + Have you ever had torsion/tvisting of the testicles? O Yes QNo + Did youhave mumps after puberty? D Yes ONo + Have you had injwy to your testicles requising an ER visit or hospitelizetion? OD Yes ONo + Have you been diegnosed with any of the following diseases? C Diabetes ellitus Cancer Cl Multiple Sclerosis Other newologe problems - Prostatic infections 0 Urinary infections - High Blood Pressure - If yes, any medications? + Have you had fever (>101° F) in the lest 3 months? O Yer ONo + Have you had e vasectomy? 0 Yes(date__) No If yes, have you hed a vasectomy reversal? CI Yes (date, No + Have you had varicocele axgery? QYes ONo + Have you had hernia swgery? O Yes ONo + Have you had other sugery to the scrotum ot goin eee? Yes ONo + Ave you exposed to prolonged heat in the workplace? QYes ONo + Ave you exposed to any radiation or hermful chemicals in the workplace? O Yes ONo + Have you had chemotherapy or radiation for cance? O Yes ONo Page?++ Are you allergic to any medications? G Yes No If yes, please list and describe reactions List your cwzent medications List any current medical problem(s): + How many caffeinated beverages do you deink per day? None + Do you smoke cigarettes? Oi Yes How many/day?, How many years? Quit - when? No + Do you drink alcohol” B Yes GNo If yes, how many drinks per week? + Have you casually used manjuana, cocaine, or any other smnilar drug? Cl Yes (Gessibe, ) Ne + Do you use herbal medicines/vitemins or heelth food store supplements? Li Yes (descxibe, )ONo + Are you aware of any solvents/taric matestals expose? G Yes No + Do youuse hot tubs regularly? Yes GNo + Did your mother take DES during pregnancy to prevent miscarriage? Yes No _ © Don't mow + Have any of your immediate femily members had difficulty conceiving child? Yes. GNo If yes please describe, Family History Living Cause of DeathvAge at Denth Whats yourAncesay? Mother Ore + Father ONo Cl American Indien or Alaskan Native + Brothes(3) ONo ONo nose + Sister(s) No BP EAS St SPH ic Ongin ONo + Matemal Grandmother OYes~ age No O Hispanic *Matemal Grandfether Yes age ONo Co White, not of Hispanic Origin + Paternal Grandmother Yes age ONo + Paternal Grandfather Yer age No 1D Other (specify Disorders in Your Family Relationship to You + Bloom syndrome ves No Don't Know + BonefSkeletel Defects OYes No Don't Know + Canavan disease ves No Don't Know + Color Blindness ves No Don't Know + Cystic Fibrosis ves No Don't Know + Deafness/Blindness — OYes No Don't Know + Developmental delay Yes No Don't Know + Down symdrome Yes No Don't Know + Otter chuomosome defects C1Yes No Don't Know + Dwarfism OYes No Don't Know + Familial Dysautonia Yes No Don't Know + Fanconi Anemia ves No Don't Know + Galactosemia ves No Don't Know + Gaucher disease ves No Don't Know + Heat defect from bith OYes No Don't Know +Hemochromatoss — OYes No Don't Know + Hemophilia ves No Don't Know + Leaming problems — OYes No Don't Know ‘+ Marfan syndrome Yes No Don't Know + Muscular Dystrophy Yes No Don't Know + Neural Tube Defects OYes No Don't Know + Neurologic (brain/spins) OYes No Don't Know Page®+ Niemann-Pick disease Yes No Don't Know + Polycystic kidney disease OYes No Don't Know +SickleCell Anemia Yes No Don't Know + Tay-Sachs disease Yes No Don't Know + Thalassemia OYes No Don't Know + High blood presse Yes No Don't Know + Glaucoma OYes No Don't Know + High cholesterol OYes No Don't Know + Gallstones OYes No Don't Know + Hepatitis OYes No ODon't Know (None of the above Other Gpeaify ‘SPOUSE /MALE PARTHER’S SIGNATURE. DATE. I confirm that I have reviewed the information above. PHYSICIAN'S SIGNATURE a. Page®