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PATIENT QUESTIONNAIRE

1. IDENTIFYING INFORMATION

NAME_____________________________PARTNER´S
Karen Idaly Morales Rivera NAME_________________________
Av. Chetumal, SM 253 M 1 L 413, Residencial Vista Alegre, Cancun Quintana Roo 77518
ADDRESS__________________________________________________________________
6564476930
PHONE NUMBER_________________________________ Antes de las 9:00am
TIME TO CALL_____________

AGE_____DATE
25 OF BIRTH_______________
25/07/1998 PARTNER AGE_______ DOB_______________

OCCUPATION_______________________PARTNER
Agente telefonico OCCUPATION____________________

HOW YOU KNEW ABOUT US? _________________________________________________

Facebook

IN WHICH TREATMENT ARE YOU INTERESTED? ___________________________________

IUI

HOW LONG HAVE YOU BEEN TRYING TO CONCEIVE? _______________________________

HAVE YOU BEEN PREGNANT? YES / NO. HOW MANY TIMES? 2_______________________

HOW WAS THE OUTCOME? __________________________________________________

Natural Birth

2. MEDICAL HISTORY
WEIGHT ________________
68kg HEIGHT _______________
1. BLOOD TYPE _________________
0+
DO YOU FOLLOW ANY PARTICULAR DIET? _______________________________________
No
DO YOU DO EXERCISE? ____________________
No 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

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HAVE YOU EVER BEEN TREATED FOR ANY DESEASE? WHAT WAS THE TREATMENT?
__________________________________________________________________________
Gastritis, pantroprazol
__________________________________________________________________________

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

__________________________________________________________________________
no
__________________________________________________________________________

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

COFFEE-HOW MANY CUPS PER DAY?___________________________________________

None

No BEER ______
ALCOHOL – HOW MANY GLASSES PER WEEK?WINE_____ No COCKTAIL_______
No
CIGARETTES – NUMBER OF PACK PER DAY? _____________________________________
None

RECREATIONAL DRUGS (MARIJUANA,COCAINE,ETC)_______________________________

None

Ago 6
WHEN WAS YOUR LAST GYN EXAM/PAP SMEAR?______________RESULT Normal
_____________
N/A
WHEN WAS YOUR LAST MAMMOGRAM ____________________ RESULT______________

3. MENSTRUAL AND PREGNANCY HISTORY

AGE AT FIRST PERIOD_______WHEN
16 WAS THE FIRST DAY OF LAST PERIOD?____________
4
DO YOU HAVE NORMAL AND REGULAR PERIODS? HOW LONG ARE THEY? DO THEY HURT?
REGULAR FLOW OR NOT? ___________________________________________________
Regular

________________________________________________________________________
DO YOU DO TEST FOR OVULATION? IF YES, WHAT KIND? ___________________________
No
DO YOU BLEED OR SPOT BETWEEN PERIODS? ____________________________________
No

PREGNANCY HISTORY:
1ST PREGNANCY___________________________________________________________
Normal Birth
_________________________________________________________________________
2ND PREGNANCY___________________________________________________________
Normal Birth
_________________________________________________________________________
3RD PREGNANCY___________________________________________________________
_________________________________________________________________________
4TH PREGNANCY___________________________________________________________
_________________________________________________________________________
WHERE THERE ANY COMPLICATIONS AFTER/DURING/BEFORE PREGNANCIES? None
_________
_________________________________________________________________________

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

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N/A
WHAT FORM OF CONTRACEPTION DO YOU USE? __________________________________

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

__________________________________________________________________________
N/A
IS INTERCOURSE PAINFUL OR DIFFICULT?________________________________________
N/A

4. FAMILY HISTORY
IS THERE A FAMILY HISTORY OF INFERTILITY? ____________________________________
No
IS THERE A HISTORY OF HORMONAL DISORDERS IN YOUR FAMILY (DIABETES,THYROID…)
_________________________________________________________________________
No
IS THERE A HISTORY OF DISEASE IN YOUR FAMILY?WHAT DISEASE IS?WHO HAS IT?______
_________________________________________________________________________
No
WHAT´S YOUR ANCESTRY?____________________________________________________
PARTNER´S ANCESTRY?______________________________________________________

5. FERTILITY TREATMENT HISTORY

HAVE YOU BEEN TREATED FOR INFERTILITY BEFORE? WHAT WAS THE DIAGNOSE? ______
NO
__________________________________________________________________________
HAVE YOU/PARTNER HAD ANY FERTILITY TESTS FOR INFERTILITY? RESULTS? ___________
No
__________________________________________________________________________
HAVE YOU/PARTNER HAD ANY MEDICATION FOR INFERTILITY?_______________________
__________________________________________________________________________
No
HAVE YOU HAD TUBAL REMOVAL/LIGATION?_____________________________________
HAVE YOU HAD SURGERY ON ANY PARTS OF REPRODUCTIVE SYSTEM?________________
No
_________________________________________________________________________
HAVE YOU HAD ANY ASSISTED REPRODUCTIVE TREATMENT? WHEN? WHERE? WHAT
None
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
contacto@fcamericas.com / fertilityclinicamericas.com

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