MEDICAL QUESTIONNAIRE
PERSONAL DETAILS
Date
Home Language
Patient’s Full Name & Surname
Date of Birth
Citizenship
Husband/Partner’s Full Name & Surname
Date of Birth
Citizenship
Home Address
Tel. Home
Tel. Office
Mobile
Email address
Referred by
Address
Tel.
Family Physician
Address
Tel.
August 2009
2
MEDICAL HISTORY FOR FEMALE PARTNER
Gynaecological History:
At what age did your menstrual periods start?
Do you still have periods?
If no, are you menopausal?
If yes, do you take hormone replacement therapy?
Are your periods regular?
Date of last period How long did it last?
How many days between your periods?
Do you have very painful periods?
Do you have any bleeding in between periods? If yes, explain:
Do you suffer from a vaginal discharge? If yes, explain:
Do you experience discomfort during intercourse?
When was your last PAP smear?
Have you ever had an abnormal PAP smear result? If yes, explain
Do you use contraception? If yes, what type?
Do you have any problems with passing urine?
If yes, explain
Do you have any problems with your bowels? If yes, explain:
Other Gynaecological history
Obstetric History:
Number of pregnancies Dates
Number of miscarriages Dates
Number of termination of pregnancies: Dates
Number of children:
From this relationship:
From a previous relationship:
August 2009
3
Are you Currently Breastfeeding?
Children Delivery Date Complications Height / Weight
Male /Female
1.
2.
3.
4.
5.
6.
Medical History:
Do you have any allergies: Please explain:
Do you have any present medical condition? Explain
Have you had hospitalisation for any medical condition? Explain
Are you currently taking any medication (prescribed or over the counter)?
Height in cm: Weight in kg:
Surgical History:
What previous operations did you have?
Family History:
Are there any specific medical conditions within your family? Explain
Social History:
What is your occupation?
Do you smoke? If yes, how many per day?
Do you drink alcohol? If yes, how often?
MEDICAL HISTORY FOR MALE PARTNER
Medical History:
Do you have any allergies: Please explain:
Do you have any present medical condition? Explain
August 2009
4
Have you had hospitalisation for any medical condition? Explain
Are you currently taking any medication (prescribed or over the counter)?
Do you have children from a previous relationship? Number:
Surgical History:
What previous operations did you have?
Family History:
Are there any specific medical conditions within your family? Explain
Social History:
What is your occupation?
Do you smoke? If yes, how many per day?
Do you drink alcohol? If yes, how often?
FERTILITY HISTORY AND INVESTIGATIONS FOR BOTH PARTNERS
Both Partners:
How long have you been trying to conceive:
Please describe infertility problem:
Please describe investigations performed and results of these:
Please describe infertility treatments (when, what, and detailed results):
What treatment are you planning to undergo at the Cape Fertility Clinic?
Do you require donor sperm from the Cape Cryo bank?
ANY OTHER INFORMATION
INVESTIGATION RESULTS
Please send copies of all requested test results to us by email or FaxMail. Results
should not be older than 12 months. Please direct it to the IVF Co-ordinator/Doctor
that you have been communicating with:
August 2009
5
Sr Karin Schwenke, +27 86 672 4768 or karin@capefertilityclinic.co.za
(IVF Co-ordinator for Dr Paul le Roux)
Sr Heidi Clark, +27 86 672 8937 or heidi@capefertilityclinic.co.za
(IVF Co-ordinator for Dr Sulaiman Heylen)
Lorean Swartbooi, +27 86 684 7031 or lorean@capefertilityclinic.co.za
(IVF Co-ordinator for Dr Klaus Wiswedel & Dr Saleema Nosarka)
We require copies of the following tests:
Female Partner:
Blood tests:
HIV I & II antibodies
RPR/VDRL/TPHA (Syphilis)
Hepatitis B surface antigen
Hepatitis C antibodies
Rubella IgG (immunity)
Day 3 FSH
TSH
Prolactin
Transvaginal ultrasound scan of the pelvis
HSG (hysterosalpingogram) or hysteroscopy or saline infusion sonogram
Male Partner:
Blood tests:
HIV I & II antibodies
RPR/VDRL/TPHA (Syphilis)
Hepatitis B surface antigen
Hepatitis C antibodies
Semen analysis
August 2009