PATIENT QUESTIONNAIRE

1. IDENTIFYING INFORMATION

NAME_____________________________PARTNER´S NAME_________________________

ADDRESS__________________________________________________________________

PHONE NUMBER_________________________________ TIME TO CALL_____________

AGE_____DATE OF BIRTH_______________ PARTNER AGE_______ DOB_______________

OCCUPATION_______________________PARTNER OCCUPATION____________________

HOW YOU KNEW ABOUT US? _________________________________________________

IN WHICH TREATMENT ARE YOU INTERESTED? ___________________________________

HOW LONG HAVE YOU BEEN TRYING TO CONCEIVE? _______________________________

HAVE YOU BEEN PREGNANT? YES / NO. HOW MANY TIMES? _______________________

HOW WAS THE OUTCOME? __________________________________________________

2. MEDICAL HISTORY
WEIGHT ________________ HEIGHT _______________ BLOOD TYPE _________________
DO YOU FOLLOW ANY PARTICULAR DIET? _______________________________________
DO YOU DO EXERCISE? ____________________ HOW MANY HOURS A DAY? ___________
DO YOU HAVE OR HAVE HAD ANY OF THE FOLLOWING?
ANEMIA GONORRHEA PNEUMONIA APPENDICITIS
HEART DESEASE POOR SENSE OF SMELL ARTHRITIS HEPATITIS
BLOOD TRANSFUSION HERPES BREAST MIL DISCHARGE HYPERTENSION
SEIZURES EXCESS HAIR GROWTH SYPHILIS KIDNEY INFECTION
THYROID PROBLEMS CHLAMYDIA LIVER PROBLEMS TUBERCULOSIS
CHRONIC BRONCHITIS LOSS OF BALANCE ULCERS CHRONIC HEADACHES
PELVIC INFECTION COLITIS GALLBLADDER PROBLEM MYCOPLASMA
DIABETES NEUROLOGICAL CONDIT. VENEREAL PROBLEMS DIZZINES
VISUAL PROBLEMS ENDOMETRIOSIS OVARIAN CYST EPILEPSY
VAGINITIS STD´S ALLERGIES
PARTICULARITIES
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Edificio Atrium. Int. 105 Av. Nichupté No. 20 Manzana 2, Supermanzana 19 Cp. 77505 Cancún Q. Roo. México
contacto@fcamericas.com / fertilityclinicamericas.com

Teléfono: (52) 998 884 5305 / (52) 998 253 7173

 HAVE YOU EVER BEEN TREATED FOR ANY DESEASE? WHAT WAS THE TREATMENT?
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DO YOU TAKE MEDICATION? REGULAR OR HERBAL? FOR WHAT CONDITION?

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DO YOU USE OR HAVE YOU EVER USED ANY OF THESE?

COFFEE-HOW MANY CUPS PER DAY?___________________________________________

ALCOHOL – HOW MANY GLASSES PER WEEK?WINE_____ BEER ______ COCKTAIL_______

CIGARETTES – NUMBER OF PACK PER DAY? _____________________________________

RECREATIONAL DRUGS (MARIJUANA,COCAINE,ETC)_______________________________

WHEN WAS YOUR LAST GYN EXAM/PAP SMEAR?______________RESULT _____________

WHEN WAS YOUR LAST MAMMOGRAM ____________________ RESULT______________

3. MENSTRUAL AND PREGNANCY HISTORY

AGE AT FIRST PERIOD_______WHEN WAS THE FIRST DAY OF LAST PERIOD?____________
DO YOU HAVE NORMAL AND REGULAR PERIODS? HOW LONG ARE THEY? DO THEY HURT?
REGULAR FLOW OR NOT? ___________________________________________________
________________________________________________________________________
DO YOU DO TEST FOR OVULATION? IF YES, WHAT KIND? ___________________________
DO YOU BLEED OR SPOT BETWEEN PERIODS? ____________________________________

PREGNANCY HISTORY:
1ST PREGNANCY___________________________________________________________
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2ND PREGNANCY___________________________________________________________
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3RD PREGNANCY___________________________________________________________
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4TH PREGNANCY___________________________________________________________
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WHERE THERE ANY COMPLICATIONS AFTER/DURING/BEFORE PREGNANCIES? _________
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Edificio Atrium. Int. 105 Av. Nichupté No. 20 Manzana 2, Supermanzana 19 Cp. 77505 Cancún Q. Roo. México
contacto@fcamericas.com / fertilityclinicamericas.com

Teléfono: (52) 998 884 5305 / (52) 998 253 7173

 WHAT FORM OF CONTRACEPTION DO YOU USE? __________________________________

HOW MANY TIMES PER WEEK DO YOU AND YOUR PARTNER HAVE SEXUAL INTERCOURSE?

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IS INTERCOURSE PAINFUL OR DIFFICULT?________________________________________

4. FAMILY HISTORY
IS THERE A FAMILY HISTORY OF INFERTILITY? ____________________________________
IS THERE A HISTORY OF HORMONAL DISORDERS IN YOUR FAMILY (DIABETES,THYROID…)
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IS THERE A HISTORY OF DISEASE IN YOUR FAMILY?WHAT DISEASE IS?WHO HAS IT?______
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WHAT´S YOUR ANCESTRY?____________________________________________________
PARTNER´S ANCESTRY?______________________________________________________

5. FERTILITY TREATMENT HISTORY

HAVE YOU BEEN TREATED FOR INFERTILITY BEFORE? WHAT WAS THE DIAGNOSE? ______
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HAVE YOU/PARTNER HAD ANY FERTILITY TESTS FOR INFERTILITY? RESULTS? ___________
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HAVE YOU/PARTNER HAD ANY MEDICATION FOR INFERTILITY?_______________________
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HAVE YOU HAD TUBAL REMOVAL/LIGATION?_____________________________________
HAVE YOU HAD SURGERY ON ANY PARTS OF REPRODUCTIVE SYSTEM?________________
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HAVE YOU HAD ANY ASSISTED REPRODUCTIVE TREATMENT? WHEN? WHERE? WHAT
PROCEEDURE WAS IT? WHAT WAS THE OUTCOME?_______________________________
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THANK YOU FOR THE VALUABLE TIME YOU HAD TO FILL OUT THIS FORM, WE WILL REVISE
IT WITH A MEDICAL SPECIALIST, SO WE CAN GIVE YOU THE BEST RECOMMENDATION.

*If you have any recent tests results please submit them to:
carolina@fertilityclinicamericas.com

Edificio Atrium. Int. 105 Av. Nichupté No. 20 Manzana 2, Supermanzana 19 Cp. 77505 Cancún Q. Roo. México
contacto@fcamericas.com / fertilityclinicamericas.com

Teléfono: (52) 998 884 5305 / (52) 998 253 7173