FEMALE HEALTH QUESTIONNAIRE Date: ________________________________ Name: _________________________________________________________________ DOB: ___________________ Race: _______________________ Religion: ___________________________ Blood type: ______________________ Reason for visiting our office today: _______________________________________________________________ _____I am here because I wish to become pregnant now or in the future _____I am here for services related to my health care other than pregnancy or fertility at this time. PREGNANCY HISTORY Please complete as applies to your care-­‐ _____I HAVE NEVER BEEN PREGNANT Number of pregnancies Number of abortions Number of miscarriages Number of ectopic pregnancies Number of living children Number of preterm births Type of delivery Pregnancy Delivery date (vaginal/c-­‐section) Birth weight Complications Updated 03/20/2014
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Check if yes Updated 03/20/2014
Past Medical Problems Anemia Anxiety or Depression Appendicitis/Appendectomy Arthritis Asthma Birth Defect Bladder/Kidney Disease Blood Transfusion Blood Clot in Legs or lung Bowel Problems Breathing Problems Cancer Chicken Pox/ or Vaccination Chlamydia or Gonnorrhea Diabetes Ear or hearing Problem Endometriosis Epilepsy or Seizures Eye or vision problem Gall Bladder Disease Genital Warts/HPV German Measles Hay Fever/Seasonal Allergies Head Injury Heart Disease, MVP or Murmur Hemophilia/blood clotting disorder Hepatitis, Jaundice or Liver Problems Hernia Hemorrhoids Herpes High blood pressure Kidney Stone Mental Illness or Psychiatric Disorder Migraine Headaches Mumps Pelvic Pain Polio Pneumonia Sexually Transmitted Disease/PID Sickle Cell Disease Stroke Thyroid Problems Tubal Disease Tuberculosis Ulcers/reflux or stomach problems Vaginitis or yeast infections-­‐Chronic Comment shared/patient services/forms/new patient forms/female health questionnaire
OTHER CURRENT Dose How Often Reason MEDICATIONS/VITAMINS DRUG ALLERGIES________________________________________________________ OTHER ALLERGIES_______________________________________________________ Surgical History ____Check if never had surgery, otherwise list below Date Physician Surgery Reason Complication Vaccines Yes/when No or unsure Comments HPV/Gardasil Rubella tDAP(tetanus/Pertusis) Flu Shot GYN HISTORY-­‐ Age Period Started?_____________________ First Day of Last Period?__________________ Date of period prior to that?_________________ My periods usually occur every________________days. My periods usually last __________________days. HAVE YOU EVER TESTED POSITIVE FOR: HPV______Herpes_____Chlamydia_____ Gonorrhea_______ LAST PAP SMEAR-­‐_____________ HISTORY OF ABNORMAL PAP?__________ DATE AND TREATMENT OF ABNORMAL PAP__________________ Updated 03/20/2014
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LAST MAMMOGRAM____________NOT APPLICABLE_____ SYMPTOMS yes no comments Chest Pain Shortness of Breath Nipple Discharge Breast Lump Pain with periods Heavy Periods Irregular Periods Bleeding with sex Bladder Problems Constipation Diarrhea Problems with Intercourse -­‐pain with sex -­‐Dryness Hot Flashes Insomnia -­‐snoring? -­‐restless legs? Please check frequency of intercourse-­‐if applicable ______>4 times a week______3-­‐4 times a week______1-­‐3 times a week ______0-­‐1 time a week________1-­‐2 times a month_____less than once a month Do you use lubricants?__________________ Do you Douche? If so how often and when?_______________________ Previous testing/treatment for infertility: ________Not Applicable Date Physician Test Results Symptoms or special testing For Metabolic Disorders-­‐ Yes No Comment Weight Loss Weight Gain Milk from Nipples Excess Facial Hair Testing for Diabetes MRI of Brain MRI of Pelvis Updated 03/20/2014
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Please Check types of Birth Control you have used in the past-­‐ ________Pill________Condoms_______IUD________Patch______Diaphragm ________Depoprovera_______NuvaRing _______Vasectomy_______Tubal Ligation FAMILY HISTORY: yes No Who In Family/Comments Asthma Allergy -­‐-­‐-­‐-­‐Dairy Allergy -­‐-­‐-­‐-­‐Wheat/Gluten Birthdefects/Mental Retardation Blood Clots Cancer -­‐-­‐Breast Cancer -­‐-­‐Colon Cancer -­‐-­‐Ovarian Cancer Diabetes DVT/ Pulmonary Embolism Epilepsy/Convulsion Heart disease Hemophilia Hepatitis High Blood Pressure Kidney/Urinary disease Mental illness Pregnancy Loss Sickle Cell Disease STD’s Stroke Thalassemia Thyroid Disorder Tuberculosis Twins/Triplets other SOCIAL HISTORY Hobbies: ________________________________________________________________________ Alcohol: ___________________ Tobacco: ______________ Recreational Drugs: _____________ Have you ever received counseling? Yes / No If so, for what reason?______________________________________________________________ Do you have Cats?________________Other pets?_____________________ How many CT Scans or X-­‐Rays have you ever had?____________________ Do you have other exposure to radiation or dangerous chemicals?________________ Have you ever had radiation for treatment of cancer?_______________ Have you ever had Genetics Testing? ___Never, if yes check all that apply ___Cystic Fibrosis___Thalasemia___Karyotype___Sickle Cell___Tay Sachs ____BRCA Gene ____Other-­‐___________________________________ Updated 03/20/2014
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YOUR DAILY DIET AND EXERCISE HABITS-­‐ Please describe your usual eating habits. We encourage patients to keep a food journal. Breakfast: _________________________________________________________________________ Lunch: ____________________________________________________________________________ Dinner: ___________________________________________________________________________ Snacks: ___________________________________________________________________________ Drinks:____________________________________________________________________________ Structured Diet Plan: ________________________________________________________________ Diet Pills: __________________________________________________________________________ Exercise and frequency________________________________________________________ Updated 03/20/2014
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Please take a moment to complete this referral form. Thank you! Patient Name: ______________________________________ Family Doctor / Primary Care Physician: Email: ______________________________________ ______________________________________ OB/GYN Physician: ______________________________________ Please indicate which of the following sources MOST INFLUENCED your decision to contact us and seek care (CHOOSE ONE): Patient Referral: ________________________ Referring OB/GYN: _________________ Delaware Today Facebook Fertility Assessment on RAD website Google Ad Google Search Insurance Company Newsletter RAD Website Radio Ad – WJBR 99.5 Radio Ad – WSTW 93.7 Twitter Women’s Journal Word of Mouth Other: ________________________________
Please circle ALL of the following sources where you have heard/seen about RAD: Christiana Care Employee Insurance Company RAD Website Co-­‐worker Local Book Twitter Community Newspaper Newsletter Verizon Yellow Pages Delaware TV Program Online – Google Ad WJBR (Radio Ad) DOCS Online – Google Search Women’s Journal Dover Air Force Base Online – Other: Word of Mouth Embryos Alive ____________________ WSTW (Radio Ad) Facebook Pt Education Seminar Yellow
Family Member RAD Employee: Friend ____________________ Google RAD Patient: ____________________ Updated 03/20/2014
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