Doctor’s notes
Lori Arnold, M.D., F.A.C.O.G
Reproductive Endocrinology and Fertility
NEW PATIENT HISTORY
A.
FEMALE IDENTIFYING DATA
Date this form completed _________________
Your name: ________________________________________ Partner’s Name: _____________________________________
Age _______________ Birth date __________________ Height _________________ Weight ________________________
How long have you been trying to get pregnant? _______________________________
Have you previously been pregnant? ___________________________
Have you previously tried to get pregnant? ______________________
Reason for your visit today? ________________________________________________________________________________
________________________________________________________________________________________________________
B. PREGNANCY HISTORY Times pregnant _________ Term births _________ Premature births _________
Miscarriages ___________ Elective abortion __________ Adopted children __________
Pregnancies: Pregnancy
Outcome (miscarriage, abortion, ectopic, vaginal
delivery, cesarean section, stillbirth, complications
Fifth
Comments: ______________________________________________________________________________________________
Contraceptive Use
C. MENSTRUAL HISTORY
Menstrual (hormonal) history
Date your last menstrual period began _________________________________________________________________
Your age at your first period ________________________________________________________________________
Are your periods regular? ___________________________________________________________________________
How many days from onset to onset? _________________________________________________________________
How many days does your period last? ________________________________________________________________
Do you bleed between periods? _____________________________________________________________________
Do you have premenstrual symptoms almost always rarely never
Have you ever needed medication to bring on your period? Yes
If yes, what medication: _________ _______________
When? ____________________________________
If you have a hormonal disorder, please specify and treatment _____________________________________________
_______________________________________________________________________________________________
Pelvic pain/cramps: none during your period before your period after your period
at mid-cycle during intercourse with urination with bowel movements
cause you to miss usual activities cause you to miss work
Pelvic cramps/pain are: mild moderate severe getting worse improving
not changing on the right side on the left side in the middle
What medications do you take for pain/cramps? _________________________________________________________
Do you have painful intercourse:
If you answered yes to any questions, please explain ______________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Gynecologist: _______________________________________________________________________________________ Primary Care Physician: ________________________________________________________________________________ Last Pap smear _________________
Any abnormal Pap smears? ___________, dates _______________________
If yes, explain: __________________________________________________________________________________________ How many times per week do you have sexual intercourse?
How many times do you have intercourse around ovulation?
F. MEDICAL HISTORY
Past Medical History
If yes, explain _______________________________________________________________________________________ List all serious or chronic illnesses or injuries not already described _____________________________________________
Medications: Please list all prescriptions and over-the-counter drugs used during the past year.
Medication
Allergies
To what (drug or substance)?
G. PAST SURGICAL HISTORY
Operations and Hospitalizations
Date
H. FEMALE FAMILY HISTORY Ethnic background (circle): African/American
Comments: __________________________________________________________________________________________ H. SOCIAL HISTORY
Cigarettes – packs smoked/day _______________________________________________________________________
Alcohol – type and number of drinks/week ______________________________________________________________
Marijuana – amount ________________________________________________________________________________
Other drugs – type and amount _______________________________________________________________________
Ever used intravenous drugs? _________________________________________________________________________
How much do you exercise? __________________________________________________________________________
Comments: ___________________________________________________________________________________________ I. PREVIOUS EVALUATION Have you had:
Abnormal
(if known)
Basal body temperature (BBT)
Abnormal
(if known)
Comments: ___________________________________________________________________________________________ K: PREVIOUS TREATMENT
Approx dates
Approx dates
Please use the remainder of this page to explain any additional information you think the doctor may need.
Source: http://wp.cacrm.com/wp-content/uploads/2012/08/CACRM_Female-History-Form.pdf
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