PATIENT QUESTIONNAIRE

1. IDENTIFYING INFORMATION

NAME PARTNER´S NAME

ADDRESS

PHONE NUMBER TIME TO CALL

AGE DATE OF BIRTH PARTNER AGE DOB

OCCUPATION PARTNER OCCUPATION

HOW YOU KNEW ABOUT US?

IN WHICH TREATMENT ARE YOU INTERESTED?

HOW LONG HAVE YOU BEEN TRYING TO CONCEIVE?

HAVE YOU BEEN PREGNANT? YES / NO. HOW MANY TIMES?

HOW WAS THE OUTCOME?

2. MEDICAL HISTORY
WEIGHT HEIGHT BLOOD TYPE
DO YOU FOLLOW ANY PARTICULAR DIET?
DO YOU DO EXERCISE? HOW MANY HOURS A DAY?
DO YOU HAVE OR HAVE HAD ANY OF THE FOLLOWING?
ANEMIA GONORRHEA PNEUMONIA APPENDICITIS
HEART DESEASE POOR SENSE OF SMELL ARTHRITIS HEPATITIS
BLOOD TRANSFUSION HERPES BREAST MIL DISCHARGE HYPERTENSION
SEIZURES EXCESS HAIR GROWTH SYPHILIS KIDNEY INFECTION
THYROID PROBLEMS CHLAMYDIA LIVER PROBLEMS TUBERCULOSIS
CHRONIC BRONCHITIS LOSS OF BALANCE ULCERS CHRONIC HEADACHES
PELVIC INFECTION COLITIS GALLBLADDER PROBLEM MYCOPLASMA
DIABETES NEUROLOGICAL CONDIT. VENEREAL PROBLEMS DIZZINES
VISUAL PROBLEMS ENDOMETRIOSIS OVARIAN CYST EPILEPSY
VAGINITIS STD´S ALLERGIES
PARTICULARITIES

Edificio Atrium. Int. 105 Av. Nichupté No. 20 Manzana 2, Supermanzana 19 Cp. 77505 Cancún Q. Roo. México
contacto@fcamericas.com / fertilityclinicamericas.com

Teléfono: (52) 998 884 5305 / (52) 998 253 7173

 HAVE YOU EVER BEEN TREATED FOR ANY DESEASE? WHAT WAS THE TREATMENT?

DO YOU TAKE MEDICATION? REGULAR OR HERBAL? FOR WHAT CONDITION?

DO YOU USE OR HAVE YOU EVER USED ANY OF THESE?

COFFEE-HOW MANY CUPS PER DAY?

ALCOHOL – HOW MANY GLASSES PER WEEK?WINE BEER COCKTAIL

CIGARETTES – NUMBER OF PACK PER DAY?

RECREATIONAL DRUGS (MARIJUANA,COCAINE,ETC)

WHEN WAS YOUR LAST GYN EXAM/PAP SMEAR? RESULT

WHEN WAS YOUR LAST MAMMOGRAM RESULT

3. MENSTRUAL AND PREGNANCY HISTORY

AGE AT FIRST PERIOD WHEN WAS THE FIRST DAY OF LAST PERIOD?
DO YOU HAVE NORMAL AND REGULAR PERIODS? HOW LONG ARE THEY? DO THEY HURT?
REGULAR FLOW OR NOT?

DO YOU DO TEST FOR OVULATION? IF YES, WHAT KIND?

DO YOU BLEED OR SPOT BETWEEN PERIODS?

PREGNANCY HISTORY:
1ST PREGNANCY

2ND PREGNANCY

3RD PREGNANCY

4TH PREGNANCY

WHERE THERE ANY COMPLICATIONS AFTER/DURING/BEFORE PREGNANCIES?

Edificio Atrium. Int. 105 Av. Nichupté No. 20 Manzana 2, Supermanzana 19 Cp. 77505 Cancún Q. Roo.
México

Teléfono: (52) 998 884 5305 / (52) 998 253

 WHAT FORM OF CONTRACEPTION DO YOU USE?

HOW MANY TIMES PER WEEK DO YOU AND YOUR PARTNER HAVE SEXUAL INTERCOURSE?

IS INTERCOURSE PAINFUL OR DIFFICULT?

4. FAMILY HISTORY
IS THERE A FAMILY HISTORY OF INFERTILITY?
IS THERE A HISTORY OF HORMONAL DISORDERS IN YOUR FAMILY (DIABETES,THYROID…)

IS THERE A HISTORY OF DISEASE IN YOUR FAMILY?WHAT DISEASE IS?WHO HAS IT?

WHAT´S YOUR ANCESTRY?

PARTNER´S ANCESTRY?

5. FERTILITY TREATMENT HISTORY

HAVE YOU BEEN TREATED FOR INFERTILITY BEFORE? WHAT WAS THE DIAGNOSE?

HAVE YOU/PARTNER HAD ANY FERTILITY TESTS FOR INFERTILITY? RESULTS?

HAVE YOU/PARTNER HAD ANY MEDICATION FOR INFERTILITY?

HAVE YOU HAD TUBAL REMOVAL/LIGATION?

HAVE YOU HAD SURGERY ON ANY PARTS OF REPRODUCTIVE SYSTEM?

HAVE YOU HAD ANY ASSISTED REPRODUCTIVE TREATMENT? WHEN? WHERE? WHAT
PROCEEDURE WAS IT? WHAT WAS THE OUTCOME?

THANK YOU FOR THE VALUABLE TIME YOU HAD TO FILL OUT THIS FORM, WE WILL REVISE
IT WITH A MEDICAL SPECIALIST, SO WE CAN GIVE YOU THE BEST RECOMMENDATION.

*If you have any recent tests results please submit them to:
carolina@fertilityclinicamericas.com

Edificio Atrium. Int. 105 Av. Nichupté No. 20 Manzana 2, Supermanzana 19 Cp. 77505 Cancún Q. Roo.
México

Teléfono: (52) 998 884 5305 / (52) 998 253