Long distance questionnaire

LONG DISTANCE QUESTIONNAIRE
Date__________________ How did you hear about our clinic? ____________________________ Name __________________________________ Soc. Sec.# _______________________ Home Phone ____________________ Work Phone ___________________ Cell Phone ______________________ Email Address ______________________________ Address ____________________________________________________________ City ________________________ State ____________ Zip Code ______________ Occupation _____________________________ Employer ______________________________ Male Partner Name ____________________________ Soc. Sec.#_____________________ Home Phone ____________________ Work Phone ___________________ Cell Phone ______________________ Email Address ______________________________ Address ____________________________________________________________ City ________________________ State ____________ Zip Code ______________ Occupation _____________________________ Employer ______________________________ SOCIAL HISTORY
Are you married? _____ How long have you been married (or together, if not married)? ________ How long have you been trying to get pregnant? ________________ How long have you been trying with a doctor's help?_______________ Was the doctor a Gynecologist or a Reproductive Endocrine / Infertility Specialist? ____________ How many times a month do you have intercourse? _____ Does either partner smoke? _____________ How much? ___________________________ Does either partner use recreational drugs? ______ Which ones? _____________________ FEMALE HISTORY

Age_____ Birthdate ________ Height_________ Weight__________ Menstrual periods occur every ________ days. Are they regular? ______________________ For how many days do you bleed? _________ Do you have endometriosis? ___________________________________________________ Do you have any medical problems? _________ Give details, including current medications: ___________________________________________________________________________ Do you have any medication allergies? Which medications?____________________________ Have you ever had pelvic inflammatory disease (PID)? ________________________________ What pelvic surgeries have you had? _______________________________________________ Number of pregnancies with this partner and outcomes _________________________________ Number of pregnancies with a previous partner _______ MALE HISTORY

Age_____ Birthdate ________ Height_________ Weight__________ Number of pregnancies with a previous partner _______ Do you have problems with erection or ejaculation? _________________________________ Do you have any medical problems? ____________ Give details, including any medications: ___________________________________________________________________________ Do you have any medication allergies? Which medications?____________________________ TESTING AND TREATMENT HISTORY
Have you had?
AMH, anti-mullerian hormone (blood test) Procedure
How many?
Any success?
Clomiphene (Clomid) stimulation with intercourse Clomiphene stimulation with insemination Injectable FSH stimulation with intercourse Injectable FSH stimulation with insemination Inseminations without any drug stimulation Is there anything else we should know about your case? Are there other pertinent test results, procedures or problems? Are there specific questions you would like addressed?

Source: http://www.advancedfertility.com/download_files/Long%20distance%20questionnaire.pdf