The Fertility Connection
437 South Selby Boulevard
Worthington, OH 43085
United States
ph: 614 519 1326
hannahca
Printing this page and completing it prior to your appointment saves lots of time and helps to fine-tune your treatment. All information is completely confidential and NEVER shared with anyone.
Name___________________________
Address_________________________
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Home phone_____________________
Cell___________________________
Email___________________________
Date____________________________
Date of Birth___________________________________
Emergency contact ______________________________
Last Day 3 FSH and AMH___________
Last TSH___________________________
Which day of your cycle was the TSH drawn__________________________
Have you had a complete thyroid panel with antibodies_______________________
If so please list results or bring a copy.
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Do you have regular menstrual cycles _______________________________
If not, how often are they _____________________________
What medications do you take regularly _______________________________
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What meds do you use occasionally_______________________________
_______________________________ List any diagnostic fertility tests you have had & the results eg. laparoscopy, HSG, Clomid challenge________________ _______________________________
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Do you know what your peak-plus-7 progesterone usually is_________________
Do you know which day of your cycle you ovulate on__________________________
How do you monitor ovulation____________
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Do you notice that you have good cervical mucus before and during ovulation__________________________
Which days have the best mucus___________ Do you chart your basal temperatures_______
Please make copies of recent charts if possible
What infertility diagnosis have you received________________________ _______________________________
What kind of sperm tests has your partner had / where was test done____________
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What were the results______________
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How old is the male partner__________
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Health problems of male partner_______
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What meds does the male use regularly / occasionally_____________________
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What is the alcohol / tobacco use of male partner_________________________
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List the dates and gestational length of any miscarriages / stillbirths & cause if known__________________________
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Have you had blood tests for miscarriage risks eg. ANA, APA, MTHFR, Protein C, Protein S? If so please bring copies.
Please list all allergies that you have___________________________ _______________________________
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List all surgeries you have had and approximate dates________________ _______________________________
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List all serious illnesses and approx. dates___________________________
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Do you easily gain weight?_______________________________
Do you find it hard to lose weight?_______________________________
Do you have low body fat?___________
How much how often do you work out / exercise_________________________
How often / how much caffeine do you consume________________________
How often / how much alcohol do you consume________________________
Are there any auto-immune diseases in your family eg. MS, Lupus, Hashimotos, Rheumatoid Arthritis_______________
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Are there any blood clotting disorders in your family______________________
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Is there a history of infertility or miscarriage in your family_________________________
Rate the following symptoms from 0 - 3 3=very intense/frequent symptom 0=zero
Menstrual cramps 0 1 2 3
Clotting of menses 0 1 2 3
Pre-menstral syndrome 0 1 2 3
Heavy menses 0 1 2 3
Very light & short menses 0 1 2 3
Do you feel tired on waking 0 1 2 3
Tire easily through the day 0 1 2 3
Do you sleep poorly 0 1 2 3
Do you find it hard to get to sleep 0 1 2 3
Do you wake frequently at night 0 1 2 3
Do you feel cold often 0 1 2 3
Do you have cold extremeties 0 1 2 3
Do you feel hot often 0 1 2 3
Do you have night sweats 0 1 2 3
Do you have headaches 0 1 2 3
Do you have migraines 0 1 2 3
Do you have irritable bowel 0 1 2 3
Do you easily get constipated 0 1 2 3
Do you have a loose stool 0 1 2 3
Do you have indigestion 0 1 2 3
Do you ever have vaginitis 0 1 2 3
Do you have yeast infections 0 1 2 3
Do you crave sugar 0 1 2 3
Do you feel stressed a lot 0 1 2 3
Do you feel easily overwhelmed 0 1 2 3
Do you feel tense frequently 0 1 2 3
Do you feel tearful frequently 0 1 2 3
Premenstrual syndrome 0 1 2 3
Have you been anemic 0 1 2 3
What kind of PMS symptoms do you have______________________
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What do you do to relax and unwind________
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What kind of work-out / exercise do you do and how often__________________________
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How were your pregnancies______________
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How were your childbirths_________________________
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Did you conceive your prior children easily / naturally / with IVF___________________
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If you have had previous IVF cycles please make note of the following:
1.The dose of meds you took and the kind of medication, eg. Follistim, lupron____________________________
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3. How many eggs were retrieved__________
4. How many eggs fertilized______________
5. What grade embryos were @ transfer______
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6.What day transfer was eg. day 3, 4 or 5
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7. How thick was your lining _____________
8. Was your transfer difficult or easy? Were you very crampy________________________
Note any periods of time that you have used contraceptive pills____________________
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Have you had prior exposure to or treatment for Chlamidya__________________________
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Have you had your appendix removed_______
Do you use vaginal lubricants other than PreSeed, canola oil or other sperm friendly product____________________________
Add any other notes below or on a separate paper, thank you.
If you have had more than one IVF cycle please attach a separate paper with the same details. Thanks________________
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Please briefly note your medical history ________________________________
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Please list any nutritional supplements and medications that you take below_________
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If you have questions about this form please feel welcome to contact us
Copyright 2009 the fertility connection . All rights reserved.
The Fertility Connection
437 South Selby Boulevard
Worthington, OH 43085
United States
ph: 614 519 1326
hannahca