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Acupuncture Atlanta
Women's Fertility History
Patient Name Date
Only complete this form out if you are working on Infertility/Gynecological issues
Have you ever had an abnormal pap smear? Yes No
Age at which menses began
Have you ever had a cervical biopsy, Yes No
Are your periods painful? Yes No operation, cauterization or conization?
Have you ever had a venereal disease? Yes No
How many days does the pain last?
Do you get yeast infections regularly? Yes No
How many days do you normally bleed? Have you ever been diagnosed with a Yes No
chlamydial infection?
How heavy is the bleeding? Select One Do you have chronic vaginal discharge? Yes No
Do you have any sores on your genitalia? Yes No
What color is the blood? Select One
Have you ever had pelvic inflammatory disease? Yes No
Is there clotting? Yes No
Were you treated for it? Yes No
Do you have premenstrual tension? Yes No
Does your face break out before or during your period? Yes No
How?
Do your breasts become tender premenstrually? Yes No
Do you bleed or spot between periods? Yes No Date of last Pap smear
Are your menstrual cycles spaced irregularly? Yes No
Have you ever been diagnosed with uterine Yes No
How many days are there from from one period to the next? fibroids or polyps?
Have you ever been diagnosed with Yes No
Date of last menstrual period endometriosis?
Have you been diagnosed with pelvic adhesions? Yes No
Have you been diagnosed with any pelvic Yes No
How many pregnancies have you had? abnormalities?
Have you taken any medications for gynecological conditions other
Years than contraceptives?
Medication Reason How long
How many children do you have?
Medication Reason How long
Years
How many abortions have you had?
Medication Reason How long
Years
Medication Reason How long
How many miscarriages have you had?
Medication Reason How long
Years
How many times has a D&C been performed?
Medication Reason How long
Years
Have your cycles changed since they began? Yes No Have you taken oral contraceptives? Yes No
When?
How?
How long?
Do you ovulate on your own? Yes No
Have you ever had an IUD? Yes No
On what day of your cycle?
When?
Do your breasts get tender at/during ovulation? Yes No
Do you get premenstral low back pain? Yes No How long?
Do your bowel movements become loose at the Yes No Have you ever taken DepoProvera? Yes No
beginning of you period?
Have you had fertility treatments? Yes No When?
If yes, when and where? How long?
By whom? How long have you been trying to conceive?
Have you had a diagnosis relating to infertility? Yes No
What types?
Have you taken medication to help you ovulate? What was it?
Yes No
When? How is your sexual energy? Select One
Do you douche regularly? Yes No
How long?
Have your fallopian tubes been evaluated Yes No With what?
medically?
Do you use vaginal lubricants? Yes No
What were the results? Are you more than 20% over your ideal body Yes No
weight?
Have you had any tubal operations? Yes No
Are you more than 20% below your ideal body Yes No
Have you had any hormone laboratory tests Yes No weight?
performed?
Do you have a stressful occupation? Yes No
What were the results? Do you exercise regularly? Yes No
Do you have a single partner with whom you have Yes No Do you have excessive facial hair? Yes No
been trying to conceive?
Do you have excessively oily skin? Yes No
How long have you been Have you experienced excessive loss of head hair? Yes No
married or living together?
Have you noticed discharge from your nipples? Yes No
Has he had a fertility workup? Yes No
Was your mother exposed to diethylstilbestrol Yes No
What were the results? (DES) when she was pregnant with you?
Have you been exposed to any Yes No
Is your partner supportive of your wish to Yes No known environmental toxins or hormones?
conceive?
Are you presently taking steroids? Yes No
COMMENTS/NOTES