Microsoft word - new patient endocrine history form ii.doc

Medical and Reproductive History-Endocrine MEDICAL AND REPRODUCTIVE HISTORY-ENDOCRINE

FEMALE PATIENT:
(Legal) Last name:________________________ (Legal) First name:________________________ Middle initial ________
Age: __________
Soc. Security #: _______-_______-_______ Marital Status: _____single _____married ______domestic partner Legal Guardian (if patient is a minor):____________________________________________ MAILING ADDRESS: Street:_____________________________________________________ City: _______________________________ State/Providence: ________________ Zip/Postal Code: ___________________ Country: ____________________ Home Phone Number: (______)______-__________ Work Phone Number: (______)______-__________ Cell Phone Number: (_______)______-__________ Email Address: ___________________________ Medical office/physician referral (Name)________________________________________ Other ____________________________________________ Would you like medical notes sent to your other healthcare provider? If yes, please indicate which provider(s) you would like us to send medical notes to: Reason for visit:______________________________________________________________________________________ Medical and Reproductive History-Endocrine REPRODUCTIVE HEALTH HISTORY

MENSTRUAL AND PUBERTAL HISTORY

Age when you had your first menstrual period: _______ years old
The first day of your most recent menstrual period: _____ / ______ / ______
Menstrual cycle pattern during first 2 years after your first menstrual period-- (check all that apply):
Current menstrual cycle pattern-(check all that apply): How many days from the first day of one period to the first day of the next? ______days How many days of bleeding do you usually have? _____days Do you need medication to bring on a period? Yes No If yes, what type? ________________________ Do you have cramping or pelvic pain with your periods? (check one) Degree of pain (1 to 10, with 10 being most severe): _____ If you do not have periods, at what age did you stop having them? _____ years old Age when you developed pubic and/or axillary (armpit) hair: _______years old Age when you began breast development: _______years old When was your last Pap smear? _____ / _____ Have you ever had an abnormal Pap smear? Yes No If "Yes," date and treatment:___________________ Did your mother take DES while pregnant with you? Yes No If yes, when was the last one? _____/______ Medical and Reproductive History-Endocrine SEXUAL HISTORY:
Are you currently sexually active with a male partner?
Duration of current relationship:______________ How old were you when you first had intercourse: _______ years old Any pain with intercourse? Yes No Do you regularly use lubricant with intercourse? Yes No If yes, what type?_______________________ Have you ever had any sexually transmitted infections? (please check all that apply)
Have you ever had pelvic inflammatory disease? Yes No
If yes, when?_______________________________ Were you hospitalized?___________________

Time since contraception last used? _____________________________________________________
Are you currently trying to become pregnant? Yes No If you previously have been pregnant, how long has it been since the most recent pregnancy? _________ Have you ever been unable to conceive for a year or more? Yes No CONTRACEPTIVE METHOD HISTORY:

PREGNANCY HISTORY: List all pregnancies, specifying under outcome whether liveborn, stillborn, ectopic,
miscarriage or elective termination (abortion).
Medical and Reproductive History-Endocrine
PREVIOUS ENDOCRINE EVALUATION:
Have you had any of the following tests performed?

Test:

PREVIOUS TREATMENT
Please indicate if you have ever been treated with the following for non-contraceptive reasons:
Medication Type/Years Used and Result
Gonadotropins (Pergonal, Gonal F, Follistim, Dexamethasone, prednisone, or cortisone Avandia (rosiglitizone)/Actos(pioglitazone) Medical and Reproductive History-Endocrine GENERAL MEDICAL HISTORY
What is your current weight? ______ Height? ______ Usual weight? _______ Recent weight loss or gain in the past 6 months? _________________________________________________________ Approximately how much did you weigh at age 18?_____ 25?_____ 30?______ 35?______ 40?______ Are you currently being treated or being seen for any medical condition(s)? Yes If yes, please describe: ________________________________________________________________________
___________________________________________________________________________________________

REVIEW OF SYSTEMS:
Check any of the following that you are presently having or have had in the past:
Please explain any positive responses: ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ Medical and Reproductive History-Endocrine
ALLERGIES:
Latex?
If yes, specify reaction: ______________________________________ If yes, specify reaction: ______________________________________ Which meds, specify reaction:_________________________________
SURGICAL HISTORY:
Please list any major surgeries or hospitalizations in the table below. Include elective termination (abortion), ectopic pregnancy,
tubal surgery or any other surgeries:

MEDICATIONS INCLUDING: VITAMINS / HERBS / OVER THE COUNTER MEDICATION (OTC'S)
Please list all medications or treatments you are currently taking:
Medical and Reproductive History-Endocrine SOCIAL HISTORY
Current Occupation: _________________________________________________________________________________ Prior Occupation(s): _________________________________________________________________________________ Have you or do you use any of the following? EMOTIONAL STATUS: On a scale of 1 to 10, (10 being the highest) what do you estimate your average level of stress to be? _________ In the past month, have there been times when you felt down, depressed, or hopeless? Yes No Were there times during the past month when you experienced little interest or pleasure in doing things? Yes No FAMILY AND GENETIC HEALTH HISTORY
Are there any known genetic diseases or conditions that run in your family? Yes No If yes, which one(s) and whom?_______________________________________________________________________ Are there any members of your family with birth defects such as heart defect, mental retardation, neural tube defects (e.g. spina bifida) or other? Are you adopted? Yes No Ethnic background:_________________________________________________________________________________ Medical and Reproductive History-Endocrine

Please indicate which of the following conditions may be found in your family:

Heart defects ("hole in the heart", etc.) Clotting disorders (Factor V Leiden, etc.) Neurologic or neurodegenerative diseases (Alzheimer, Huntington, etc) parathyroid, thyroid disorder, Adrenal Hyperplasia) Other genetic disorders (Cystic fibrosis, marfan syndrome, neurofibromatosis, sickle cell anemia, PKU, Tay-Sachs disease, Canavan disease, etc.) Please explain any positive answers:___________________________________________________________________ __________________________________________________________________________________________________

Source: http://www.seattlefertility.biz/downloads/MedicalHistoryEndocrine.pdf