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Nova In Vitro - Comprehensive History Form
Nova In Vitro
Fertilization
2500 Hospital Drive, Building 7, Mountain View, CA 94040
650 -325 -NOVA (6682)
novaivf.com
1
Comprehensive Medical History Form
Date:
Who referred you to our practice?
Former Patient
Friend
SART Data
Self-referral
Yelp
Physician - please
list name:
Internet Search-
please specify what
search terms:
Patient Information:
Patient
Partner
Name:
Date of
Birth:
Fertility Evaluation:
Duration of relationship:
years and
months
Duration of unprotected intercourse:
years and
months
How long have you been actively attempting pregnancy?
years and
months
How frequently do you and your partner have intercourse? _____ per week / _____ per month
Have you ever used a method to keep you from getting pregnant?
Yes
No
If yes, what method(s)?__________________________________________
Pregnancies (female):
Pregnancy
1
st
2
nd
3
rd
4
th
Mo/Yr of
conception
How long did it
take to
conceive?
Gender
Did your current
partner sire the
pregnancy?
Yes
No
N/A
Yes
No
N/A
Yes
No
N/A
Yes
No
N/A
Outcome
Living
Miscarriage
Ectopic
Abortion
Living
Miscarriage
Ectopic
Abortion
Living
Miscarriage
Ectopic
Abortion
Living
Miscarriage
Ectopic
Abortion
Nova In Vitro
Fertilization
2500 Hospital Drive, Building 7, Mountain View, CA 94040
650 -325 -NOVA (6682)
novaivf.com
2
Female History:
Current weight
pounds
Height
feet
______ inches
How old were you when your periods first started?
years
Did you develop regular monthly periods at that time?
Yes
No
Do you have monthly menstrual periods now?
Yes
No
If yes, what is the usual number of days
between
the start of one period to the start of the next period?
days
Dates of the 1
st
day of your last 2 menstrual periods:
___/___/___
___/___/___
How many menstrual periods do you have per year?
________
Do you have severe cramping or pelvic pain with your
menstrual periods?
Yes
No
Do you have pain with intercourse?
Yes
No
Have you been diagnosed with endometriosis?
Yes
No
Have you ever had a pelvic infection?
Yes
No
Have you ever had any of the following sexually transmitted diseases or pelvic infections?
Chlamydia
Syphilis
Gonorrhea
Herpes
Genital Warts/HPV
If known, what is the cause of your infertility?
Please complete the following table as accurately as possible, especially the “Physician/Clinic” column.
Test
Date(s)
Physician/Clinic
Results/Findings
Thyroid Test (TSH)
Day 3 blood test for
FSH/Estrogen
AMH
Prolactin level
Hysterosalpingogram
(X-Ray of Tubes/HSG)
Sonohysterography
(water ultrasound)
Hysteroscopy
Genetic Testing
comprehensive_history_form Page3
Nova In Vitro
Fertilization
2500 Hospital Drive, Building 7, Mountain View, CA 94040
650 -325 -NOVA (6682)
novaivf.com
3
Medical history:
When was your last pap smear (month/year)?
___ / ___
Normal
Abnormal
When was your last abnormal pap smear?
___ / ___
Not applicable
Do you perform self breast exams?
Yes
No
Have you ever had a mammogram?
Yes
No
When was your last mammogram?
month
year
Normal
Abnormal
Besides the tests and treatments listed above, have
you had any surgery on your vagina, cervix, uterus,
Fallopian tubes, ovaries or your abdomen?
Yes
No
If yes please list all surgeries in chronological order:
Year
Reason and Type of Surgery
Social History:
How many caffeinated beverages (coffee, soda, tea)
do you drink per day?
On average how much water are you consuming daily?
Do you exercise regularly?
Yes
No
If yes, describe:
Do you smoke cigarettes or have you ever used
tobacco products?
Yes
No
Do you drink alcohol?
Yes
No
Have you ever used illicit drugs?
Yes
No
Are you allergic to any foods?
Yes
No
If yes, describe:
Have you had significant weight change in the last year?
Yes
No
Nova In Vitro
Fertilization
2500 Hospital Drive, Building 7, Mountain View, CA 94040
650 -325 -NOVA (6682)
novaivf.com
4
Emotional Status:
On a scale of 1-10 (10 being the worst), estimate the level
of stress you feel due to infertility and other pressures:
Do you see a counselor?
Yes
No
List any anti-depressant/anti-anxiety medication you are currently taking:
Has your infertility produced marital or sexual dysfunction?
Yes
No
Family History:
Have any of these illnesses occurred in your family:
High blood pressure
Diabetes
Breast cancer
Ovarian cancer
Infertility
Immunization History:
Chickenpox (Varicella):
No
Yes (dates:
)
Don’t Know
MMR- Measles, Mumps, Rubella
(German Measles):
No
Yes (dates:
)
Don’t Know
Tetanus (Tdap):
No
Yes (dates:
)
Don’t Know
Hepatitis B:
No
Yes (dates:
)
Don’t Know
Polio:
No
Yes (dates:
)
Don’t Know
Influenza:
No
Yes (dates:
)
Don’t Know
Medications/Supplements:
Are you allergic to any medications?
No
Yes:__________________________________
Are you currently taking any medications or supplements?
If yes please list below:
Medication/Supplement
Start Date
Dose
Nova In Vitro
Fertilization
2500 Hospital Drive, Building 7, Mountain View, CA 94040
650 -325 -NOVA (6682)
novaivf.com
5
Prior Treatment:
please check all that apply
Treatment
# of
Cycles
Dates:
From (Mo/Yr) / To
(Mo/Yr)
Outcome
Intrauterine insemination (IUI)
Pregnant: (
delivered
ectopic )
Miscarriage
Not Pregnant
Clomid or Femara /
Letrozole with
intercourse
Max # tablets per day: ___
Pregnant: (
delivered
ectopic )
Miscarriage
Not Pregnant
Clomid or Femara /
Letrozole with
insemination
Max # tablets per day: ____
Pregnant: (
delivered
ectopic )
Miscarriage
Not Pregnant
Daily fertility drug injections with
insemination
Max # vials per day: ____
Pregnant: (
delivered
ectopic )
Miscarriage
Not Pregnant
Completed in vitro fertilization
cycle(s):
1.
# eggs ____
#frozen ____
#embryos transferred ____
Pregnant: (
delivered
ectopic )
Miscarriage
Not Pregnant
2.
# eggs ____
#frozen ____
#embryos transferred ____
Pregnant: (
delivered
ectopic )
Miscarriage
Not Pregnant
3.
# eggs ____
#frozen ____
#embryos transferred ____
Pregnant: (
delivered
ectopic )
Miscarriage
Not Pregnant
4.
# eggs ____
#frozen ____
#embryos transferred ____
Pregnant: (
delivered
ectopic )
Miscarriage
Not Pregnant
Frozen embryo transfer(s):
1.
# eggs ____
#frozen ____
#embryos transferred ____
Pregnant: (
delivered
ectopic )
Miscarriage
Not Pregnant
2.
# eggs ____
#frozen ____
#embryos transferred ____
Pregnant: (
delivered
ectopic )
Miscarriage
Not Pregnant
3.
# eggs ____
#frozen ____
#embryos transferred ____
Pregnant: (
delivered
ectopic )
Miscarriage
Not Pregnant
4.
# eggs ____
#frozen ____
#embryos transferred ____
Pregnant: (
delivered
ectopic )
Miscarriage
Not Pregnant
Canceled in vitro fertilization
attempt(s):
Any other prior treatment:
comprehensive_history_form Page6
Nova In Vitro
Fertilization
2500 Hospital Drive, Building 7, Mountain View, CA 94040
650 -325 -NOVA (6682)
novaivf.com
6
Male History:
Male
: pregnancies from previous marriage(s) or partner(s):
Pregnancy
1
st
2
nd
3
rd
4
th
Mo/Yr of
conception
How long did it
take to
conceive?
Gender
Outcome
Living
Miscarriage
Ectopic
Abortion
Living
Miscarriage
Ectopic
Abortion
Living
Miscarriage
Ectopic
Abortion
Living
Miscarriage
Ectopic
Abortion
Have you ever been evaluated by a urologist?
Yes
No
Do you have difficulty with erections?
Yes
No
Do you have retrograde ejaculation of sperm into the bladder?
Yes
No
Have you ever had any of the following sexually transmitted diseases or pelvic infections?
Chlamydia
Syphilis
Gonorrhea
HIV/AIDS
Herpes
Hepatitis
Genital Warts/HPV
Do you have a history of undescended testicles?
Yes
No
Do you have scrotal or testicular pain?
Yes
No
Have you had prior injury to your testicles requiring hospitalization?
Yes
No
Have you had a high fever in the last 3 months?
Yes
No
Have you had a vasectomy?
Yes
No
Have you had surgery for varicocele repair?
Yes
No
Have you had hernia surgery?
Yes
No
Did you undergo any bladder or penis surgery as a child?
Yes
No
Are you exposed to any radiation or harmful chemicals
in the workplace?
Yes
No
Have you had chemotherapy for cancer?
Yes
No
Have you ever used testosterone, androgel or androgenic hormones?
Yes
No
Nova In Vitro
Fertilization
2500 Hospital Drive, Building 7, Mountain View, CA 94040
650 -325 -NOVA (6682)
novaivf.com
7
Please complete the following table as accurately as possible, especially the “Physician/Clinic” column.
Test
Date(s)
Physician/Clinic
Results
Semen Analysis
Chromosomes
(karyotype)
Genetic Testing
Medications/Supplements:
Are you allergic to any medications?
No
Yes:__________________________________
Are you currently taking any medications or supplements?
If yes please list below:
Medication/Supplement
Start Date
Dose