Kutteh new patient h&p form

KUTTEH KE FERTILITY ASSOCIATES OF MEMPHIS, PLLC
80 Humphreys Center, Suite 307
Memphis, TN 38120-2363
Tel: (901) 747-BABY (901) 747-2229 Fax: (901)747-4446
Initial Female Evaluation
Who referred you to our care?__________________________ Who is your OB/Gyn? _____________________________FAX________________ WHAT IS THE MAIN PURPOSE OF TODAY’S VISIT (Circle as many as apply)
PHYSICIAN USE ONLY
10. Pelvic pain/Pelvic adhesions (scar tissue) 12. Recurrent pregnancy loss (miscarriages) Irregular menstrual cycles (irregular periods) Hirsutism (excess facial/body hair) Have you been treated with these medications? (Please circle) Have you ever had any of these treatments? (Please circle and indicate number of treatments) Intrauterine insemination (IUI)__________ In vitro fertilization (IVF)______________ YOUR PREGNANCY HISTORY (Please list ALL pregnancies) Blood Type?__________
//Ke Documents/Web Page/kutteh ke fert questionairre_7 Rev. 10/14/2012 KUTTEH KE FERTILITY ASSOCIATES OF MEMPHIS, PLLC
80 Humphreys Center, Suite 307
Memphis, TN 38120-2363
Tel: (901) 747-BABY (901) 747-2229 Fax: (901)747-4446
ANATOMIC-UTEROTUBAL ASSESSMENT
Have you had a hysterosalpingogram (x-ray dye test of the tubes)? Have you had a sonogram (ultrasound of the uterus/ovaries)? Have you had surgery in your abdomen or pelvis? Have you had surgery (biopsy or conization) on your cervix? Have you ever had: (Circle as many as apply) Any other sexually transmitted infection (e.g. herpes, genital warts, HPV, others) ENDOCRINOLOGIC-OVULATION ASSESSMENT
Do you have regular, predictable, spontaneous menstrual periods? ______ How many days does your period last? How many days from the first day of one period to the first day of the next? If you do not have periods, when did they stop? Do you have pre –menstrual symptoms: Yes ( ___Cramps ___breast pain, __bloating, ___mood change)
Do you have pain or cramps with your periods? Yes (___mild, ___moderate, ___ severe)
Do you have pelvic pain between your periods? Yes (when? __________________________________) No
What medicine or action helps decrease the pain? What have you used for birth control?_____________________ When did you stop? Has you ever taken medicine to start your periods? Yes (when ______ what________________________) No
Do you have or have you ever had: (Please circle) Unwanted hair on ____chin,____ sideburns, ____mustache,_____chest ____abdomen What is your weekly exercise? ___________________________________________________________ What is your weight? Currently_______ Ideally______ One year ago_______ Five years ago______ //Ke Documents/Web Page/kutteh ke fert questionairre_7 Rev. 10/14/2012 KUTTEH KE FERTILITY ASSOCIATES OF MEMPHIS, PLLC
80 Humphreys Center, Suite 307
Memphis, TN 38120-2363
Tel: (901) 747-BABY (901) 747-2229 Fax: (901)747-4446
PAST MEDICAL HISTORY/SYSTEMS REVIEW [Circle any conditions that you have or have had]
Other _____________________________________________________________________________ Surgery or hospitalizations (Give dates):
Date of your last mammogram? __________ Was it normal? No (explain__________________________)
Current Medications (include dosage, frequency, and any over-the counter or herbal drugs)
Medication Allergies
Habits: Do you use tobacco?
(_______cig/day:
(When did you quit?
(drinks/week:
FAMILY HISTORY
Is she menopausal? Yes (what age
Reason for menopause __________________) No
Yes (_____breast, ____ovarian, ____other
Yes (describe________________________________________)
Any autoimmune disease in the family? Yes (describe____________________________________ ___)
Yes (describe
Anyone in your family have? Yes (___genetic/inherited disease, ____birth defects, ___mental retardation) No
//Ke Documents/Web Page/kutteh ke fert questionairre_7 Rev. 10/14/2012 KUTTEH KE FERTILITY ASSOCIATES OF MEMPHIS, PLLC
80 Humphreys Center, Suite 307
Memphis, TN 38120-2363
Tel: (901) 747-BABY (901) 747-2229 Fax: (901)747-4446
MALE PARTNER EVALUATION P NP NA
Any previous pregnancies? Yes (Year and Outcome
Has your sperm been tested? Yes (When?
Have you had a varicocele of the scrotum? Yes (describe
Have you seen a urologist for any reason Yes (describe
Have you had? _____genital surgery, _____trauma, ______ genital infections, _____hernias? What health problems do you have?_______________________________________________
What medications do you take?___________________________________________________ smoke or use tobacco? Yes (cig/day:
use alcohol? Yes (drinks/week:
use illicit drugs? Yes (
Do you have allergies to any medications? Yes (
Does infertility run in your family? Yes (Whom?
SEXUAL HISTORY
How often do you and your partner have sexual intercourse? Do you try to time intercourse to your ovulation? Yes (how?
Do you use any lubricants during intercourse? Yes (what kind?
Do you have any pain with intercourse? Yes (where?
Do you have any other sexual difficulties as a couple? Yes (explain
RECURRENT PREGNANCY LOSS: Yes___(please answer below)
No __(skip to next page)
Genetic Factors:
Have you had a karyotype (chromosome) test? Yes (When_________Result:________________________ No
Yes (When_________Result________________________ No
Have you had karyotype test on a miscarriage? Yes (When_________Result________________________ No
Have you/your partner had any other genetic tests? Yes (When______Result________________________ No
Immunologic Factors: Do you have an autoimmune disease (e.g. lupus, rheumatoid arthritis, etc) Yes No
Personal history of autoimmune disease or abnormal immune tests? (Circle below) Yes No
Other immune tests: Describe_________________________________________________________ Thrombophilic Factors:
Do you have a history of blood clots? Yes (When ____ What type_____________________________) No
Circle any of these tests you have had: Factor V Leiden Have you ever been on a blood thinner? Yes (___Heparin, ___Lovenox,____Coumadin ____Baby Aspirin) No
//Ke Documents/Web Page/kutteh ke fert questionairre_7 Rev. 10/14/2012 KUTTEH KE FERTILITY ASSOCIATES OF MEMPHIS, PLLC
80 Humphreys Center, Suite 307
Memphis, TN 38120-2363
Tel: (901) 747-BABY (901) 747-2229 Fax: (901)747-4446
PHYSICIAN USE ONLY: PHYSICAL EXAMINATION
FEMALE DIAGNOSIS and CPT
MALE DIAGNOSIS and CPT
INFO/ADVICE
Nurse/Resident__________________________ MD __________________________ Dictated _______________ //Ke Documents/Web Page/kutteh ke fert questionairre_7 Rev. 10/14/2012

Source: http://fertilitymemphis.com/wp-content/uploads/2013/03/Infertility-Evaluation-2012-2.pdf