Clinic History Female

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1. CLINICAL HISTORY OF THE FEMALE PATIENT

**PLEASE FILL THIS FORM IN CAPITAL LETTERS**

Please leave blank any questions you do not understand or are not sure of how to answer.
We ask you to pay close attention when filling in this questionnaire, as your answers are very important. All information is confidential and will be considered as a part of your medical history.

NAME AND SURNAME:

DATE OF BIRTH:

DURATION OF INFERTILITY :

2. FAMILY HISTORY:

Among the members of your family (parents, brothers and sisters, aunts and uncles, children, nieces and nephews), is there any history of

HEREDITARY DISEASES:

CHILDREN BORN WITH DEFORMITIES:

PULMONARY EMBOLISM OR THROMBOSIS:

BREAST CANCER:

THYROID DISORDERS:

OTHER RELEVANT HEALTH CONDITIONS:

3. PERSONAL MEDICAL HISTORY (PAST OR PRESENT):

GENETIC DISEASE:

HEALTHY CARRIER OF A HEREDITARY DISEASE :

OTHER TYPES OF ANEMIA:

CANCER:

INFECTIOUS DISEASES :

PELVIC/GENITAL INFECTIONS:

ENDOMETRIOSIS:

DIABETES::

NEUROLOGICAL, PSYCHOLOGICAL, PSYCHIATRIC DISORDERS, DEPRESSION, ANXIETY:

EPILEPSY:

OTHER TYPES OF ANEMIA:

MIGRAINE:

THROMBOSIS:

HEART DISEASE:

HYPERTENSION (HIGH BLOOD PRESSURE):

THYROID DISORDERS:

ASTHMA:

NEPHRO-UROLOGICAL DISORDERS:

HEPATOPATHIES (LIVER DISEASES):

GASTRIC/DUODENAL ULCERS:

CROHN'S DISEASE:

TUBERCULOSIS:

VASCULAR CEREBRAL EVENTS:

MULTIPLE SCLEROSIS:

OTHER RELEVANT HEALTH CONDITIONS:

ALLERGIES TO MEDICATIONS/LATEX/METALS:

REACTIONS TO ANESTHETICS:

BLOOD TRANSFUSION:

MEDICATIONS TAKEN IN THE LAST 6 MONTHS:

SMOKING HABITS (CIGARS/CIGARETTES PER DAY):

ALCOHOL CONSUMPTION (GLASSES PER DAY):

DRUG CONSUMPTION:

PREVIOUS TESTS OF FERTILITY (PLEASE INDICATE THE DATES THE TESTS WERE PERFORMED):

HORMONAL TESTS (FSH, LH, E2, AMH, TSH, PROLACTIN ETC.):

HYSTEROSALPINGOGRAPHY:

HYSTEROSCOPY:

LAPAROSCOPY:

KARYOTYPE (CHROMOSOME ANALYSIS):

OTHER TESTS:

PREVIOUS SURGERIES APART FROM THOSE DESCRIBED ABOVE (APPENDECTOMY, MYOMA/FIBROID RESECTION, OVARIAN CYSTS, CERVICAL SURGERY (CONE BIOPSY) ETC.):

4. MENSTRUAL CYCLE:

YOUR AGE AT YOUR FIRST MENSTRUATION:

FIRST DAY OF YOUR LAST SPONTANEOUS MENSTRUATION:

ARE YOUR CYCLES USUALLY REGULAR?

LENGTH OF MENSTRUAL CYCLES (HOW MANY DAYS ARE THERE USUALLY BETWEEN DAY 1 OF TWO CONSECUTIVE PERIODS):

LENGTH OF MENSTRUAL BLEEDING (DAYS):

DO YOU SUFFER FROM PAINFUL MENSTRUAL PERIODS?

WHICH CONTRACEPTIVE METHODS HAVE YOU USED IN THE PAST? (NONE, PILLS, IUD, OTHERS)

PREVIOUS PREGNANCIES WITH YOUR CURRENT PARTNER:
YesNo

PREGNANCIES WITH DELIVERY (YEAR, PREGNANCY WEEK, COMPLICATIONS, MODE OF DELIVERY):

MISCARRIAGES (YEAR, PREGNANCY WEEK, CURETTAGE YES/NO):
YesNo

TERMINATION OF PREGNANCY (VOLUNTARY OR FOR MEDICAL INDICATIONS; YEAR, PREGNANCY WEEK):

ECTOPIC (EXTRAUTERINE) PREGNANCIES (YEAR, PREGNANCY WEEK, TREATMENT):

5. PREGNANCIES WITH DELIVERY (YEAR, PREGNANCY WEEK, COMPLICATIONS, MODE OF DELIVERY):

MISCARRIAGES (YEAR, PREGNANCY WEEK, CURETTAGE YES/NO):
YesNo

PREGNANCIES WITH DELIVERY (YEAR, PREGNANCY WEEK, COMPLICATIONS, MODE OF DELIVERY):

MISCARRIAGES (YEAR, PREGNANCY WEEK, CURETTAGE YES/NO):
YesNo

TERMINATION OF PREGNANCY (VOLUNTARY OR FOR MEDICAL INDICATIONS; YEAR, PREGNANCY WEEK):

ECTOPIC (EXTRAUTERINE) PREGNANCIES (YEAR, PREGNANCY WEEK, TREATMENT):

Date: