Fertility History And Information Form printable pdf download

Fertility History and Information

Acupuncture & Chinese Medicine Center

Confidential Page 1 of 3

7250 France Ave South Suite 308 Edina, MN. 55435 • Phone: 952-820-0877

PART I: (Are you a Female Patient or Partner? Please check one)

Name: __________________________________

Date of Birth: ________________ Today’s date:___________________

What are your expectations for this visit? ________________________________________________________________________________

How many months have you been having intercourse without any form of birth control? ________________ N/A

Menstrual History

What is your menstrual cycle pattern (check all that apply): ___Regular

___Irregular

___Spotting before periods

___Bleeding between periods

___Light/Heavy periods

___No periods, (at what age did you stop having them? ______)

How many days are between periods? __________

How many days of bleeding do you have? ________days

Dates of 1

day of your last 2 menstrual periods? _______/_______/______;

______/______/______

How many periods do you have per year? _______

Do you need medication to bring on a period? ___No ___Yes, what type? ________________________

Pregnancy Summary

Total Number of ALL pregnancies_______

How many children have you had? _____

Number of miscarriages (<20wks)______

Number of abortions________

Number of full term deliveries_________

Number of premature (<37 wks) deliveries ______

Date pregnancy ended or

Months to conception

Treatments to conceive

Delivery type—D&C

Current

delivered

complications

partner?

___Y; ___N

Contraceptive and Sexual History

___None

___Condoms-dates of use____________

___Birth control pill-date of use______________, Complications_______________

___Never used birth control pills

___Injectable contraception (Depo-Provera, Lunelle, etc)-dates of use_______________

___Others________________________________

Are you sexually active? ___Yes ___No;

How many times do you have intercourse per week? _____/wk;

___None ___N/A

Have you used over-counter ovulation kits to time intercourse? ___Yes ___No, ___Unable to get LH Surge Positive

Do you have pain with intercourse? ___Yes ___No; ___Use lubricants (K-Y Jelly, etc) during intercourse

Have you ever had an abnormal pap smear? ___Yes ___No, If Yes, When________________

Have you ever had a cervical biopsy? ___Yes ___No

Do you get yeast infections regularly? ___Yes ___No

Have you ever been diagnosed with a chlamydial infection? ___Yes ___No, If Yes, When_____________

Do you have a chronic vaginal discharge? ___Yes ___No

Do you have sores on your genitalia? ___Yes ___No

Have you ever had pelvic inflammatory disease (PID)? ___Yes ___No, If Yes, Were you treated for it? ___Yes ___No

Have you ever been diagnosed with uterine fibroids or polyps? ___Yes ___No, When/Treatment_____________________________________

Have you ever been diagnosed with endometriosis? ___Yes ___No, When/Treatment_______________________________________________

Have you ever been diagnosed with pelvic adhesions? ___Yes ___No, When/Treatment _____________________________________________

Have you ever been diagnosed with any pelvic abnormalities? When/Treatment______________________________________________________

Fertility History And Information Form

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