Ultrasound monitoring of follicles

California IVF: Davis Fertility Center, Inc.
1550 Drew Ave. Suite 100 Davis, CA 95618 www.californiaivf.com www.californiaconceptions.com History Questionnaire
Name: _____________________________________ Date of Birth: ______________ Age:_____ Partner: ____________________________________ Date of Birth: ______________ Age:_____ Please complete this form to the best of your ability. Complete this document only if you have
interest in donor embryo options for pregnancy. This document must be received by our office
before you will be able to proceed.
Female Fertility Questions:
Time trying to get pregnant ___ yrs ___ mos Length of time without contraception ___ yrs ___ mos Previous infertility testing  Yes  No Previous infertility treatment  Yes  No If you answer no, please skip to the next page If you answer no, please skip to the next page Comments: (include dates and results if known) HSG (hysterosalpingogram, X-ray of tubes) Laparoscopy (camera in belly in operating room) Hysteroscopy (color camera looking in uterus) Has your partner had a semen analysis? Normal? Comments: (include dates and number of treatments) ICSI – sperm injection into egg  Yes  No Frozen embryo transfer (FET)  Yes  No Have you ever received donor eggs or embryos Gynecologic History First Day of Last Period: Number of days between the start of one period and the start of the next period:  regular  very regular Amount of flow  occasionally irregular  unpredictable Cramping  none  mild  moderate  severe Last PAP smear (month/year) DDE History Questionnaire revised 9-2010.doc California IVF: Davis Fertility Center, Inc.
1550 Drew Ave. Suite 100 Davis, CA 95618 www.californiaivf.com www.californiaconceptions.com History of sexually transmitted diseases  Yes  No Pelvic inflammatory disease (PID)?  Yes  No Pain with intercourse Have you or your partner ever had a sterilization procedure? (tubal / vasectomy) Have you ever had uterine fibroids, polyps, or other problems with your uterus? Have you ever been told you have endometriosis? Please provide us with any additional information about problems that may have prevented you from getting pregnant. Obstetrical History Total number of pregnancies List each pregnancy in order including the year, outcome, route of delivery, and complications


Current Medications: List medications, name, and length of use or approximate starting date Medical History: List medical conditions or illnesses including past medical illnesses. Give approximate dates and details. Thyroid disorder DDE History Questionnaire revised 9-2010.doc California IVF: Davis Fertility Center, Inc.
1550 Drew Ave. Suite 100 Davis, CA 95618 www.californiaivf.com www.californiaconceptions.com Allergies: List allergies to medications, foods, or chemicals (not seasonal allergies or hay fever) Surgical History: List operations and surgeries you have had. Give approximate dates and indicate complications. Examples:  Tonsils,  Wisdom Teeth,  Appendix,  Breast Augmentation,  Gastric Bypass,  LASIK  Cesarean Section,  Laparoscopy,  Other Dates and Details: Surgical complications or problems with anesthesia?  Yes  No Hospitalizations (other than deliveries or surgeries listed above) Please provide additional details if applicable  Never  Socially  Frequently  Excessively Review of Systems: Check any you have now or in the past. Provide a description of any positive answers or additional items. General or Constitutional
Neurologic / Brain
DDE History Questionnaire revised 9-2010.doc California IVF: Davis Fertility Center, Inc.
1550 Drew Ave. Suite 100 Davis, CA 95618 www.californiaivf.com www.californiaconceptions.com Dermatology / Skin
Endocrine / Hormones
Eyes, Ears, & Nose
Cardiovascular / Heart
Respiratory / Lung
Allergy & Immunologic
Hematology
Thrombocytopenia (low WBC)  Yes  No Gastroenterology / Digestive
Genito-urinary
DDE History Questionnaire revised 9-2010.doc California IVF: Davis Fertility Center, Inc.
1550 Drew Ave. Suite 100 Davis, CA 95618 www.californiaivf.com www.californiaconceptions.com Muscle & Skeletal
Please sign here indicating that the statements above are true to the best of your knowledge. You should request any relevant records for review and make certain the copies are received before your appointment. Records of any infertility testing or treatment, blood tests, radiology reports pertaining to pregnancy or significant health problems, Pap smears, and mammogram reports will assist us in coordinating your care. We do not need copies of routine health records or pregnancy records unless specifically requested. _______________________________________
Office Use Only

Physician Assessment:
Discussion and Plan:
Doctor’s opinion

The laboratory results  were /  were not available at the time of this opinion. I have
reviewed the information available, and based on my assessment, the individual named
above:
 Appears healthy and without risk factors for carrying a pregnancy
 There are risk factors to pregnancy but the patient would be able to proceed with caution
 There are significant risk factors to pregnancy and the patient should seek MFM counseling
 There are significant risk factors to pregnancy and the patient should not get pregnant
_______________________________________
 Ernest Zeringue MD  Laurie Lovely MD DDE History Questionnaire revised 9-2010.doc California IVF: Davis Fertility Center, Inc
1550 Drew Ave. Suite 100 Davis, CA 95616 Male History Questionnaire
Name: _____________________________________ Date of Birth: ______________ Age:_____ Partner: ____________________________________ Date of Birth: ______________ Age:_____ Male History and Fertility Questions
Occupation: Employer: Pregnancies with current partner History of sexually transmitted diseases  Yes  No  Never  Socially  Frequently  Excessively Exposure to toxins (chemical/radiation)  Yes  No Comments: (include dates and results if known)
Ancestry
Please provide more details if applicable
Disorders
Do you or any of your family members have any of the following disorders?

Source: http://californiaconceptions.com/documents/Questionnaire.pdf