Medical History Surgery Questionnaire | Tampa Bay Infertility Experts

Your Personal Information

First Name

Last Name *

Phone Number *

Date of Birth *

Name of Primary Care Physician

Chief Complaint

Reason for Surgery *

Current Medications: List all medications or None if Not Applicable *

Allergies: List all medication allergies or None if Not Applicable *

GYN History

What age did your menses begin? *

Calendar date of last menstrual cycle *

What is the time period (in days) between your menstrual cycle? (1st day of last period to 1st day of next period) *

Do you have pelvic pain? *

No

Yes

Do you have Dyspareunia (pain with intercourse)? *

No

Yes

Have you been diagnosed with Pelvic Inflammatory Disease? *

No

Yes

Do you have Dysmenorrhea (pelvic pain with menses)? *

No

Yes

Do you have a history of Fibroids? *

No

Yes

Do you have a history of Anemia? *

No

Yes

Have you ever had Chlamydia or Gonorrhea? *

No

Yes

List STD type, year contracted & if you were treated. *

OB History

Number of pregnancies in lifetime *

Number of living children *

Have you ever had an abortion/miscarriage? *

Number of "spontaneous" abortions/miscarriages *

Number of "elective" abortions *

Have you ever had an ectopic "tubal" pregnancy? *

Provide the year and outcome of the ectopic. *

Contraceptive method(s) currently used *

Date of last PAP *

Date of last mammogram

Partner History

Partner's First and Last Name *

Partner's number of children *

List the ages of each of your partner's children *

List any medical conditions your partner has *

List any surgeries your partner has had & year performed *

List any medications your partner currently takes (include name, dosage & frequency) *

Date of semen analysis or N/A if not performed *

Patient History

List any surgeries you have had and the year performed *

List any illnesses or health concerns, past or present *

List any injuries in your medical history *

Weight (Pounds) *

Height (Feet) *

Height (Inches) *

Family History - Mother

Is your mother Living, Deceased or Unknown *

If your mother is deceased, list cause *

Family History - Father

Is your father Living, Deceased or Unknown *

If your father is deceased, list cause. *

Family History - Siblings

Number of siblings *

Number of living siblings *

Number of deceased siblings *

Cause(s) of death for any deceased sibling(s) *

Family History

(Includes: Mother, Father, In-laws, Grandparents, Aunts, Uncles, Siblings, etc.) Answer "None" if no family history.

List relationship of anyone in family with a history of diabetes *

List relationship of anyone in family with a history of heart disease *

List relationship of anyone in family with a history of hypertension *

List relationship of anyone in family with a history of ovarian cancer *

List relationship of anyone in family with a history of breast cancer *

List any other relevant health concern a family member has had & their relationship *

Social History

Do you use tobacco products? *

List type of tobacco and frequency. *

Do you drink/consume alochol? *

List the kind consumed and frequency *

Have you ever been involved in any form of domestic violence? *

Please describe. *

Do you use any drugs? *

List drug type and frequency. *

Acknowledgement

By Submitting: I acknowledge that all information provided is accurate and true. I understand that providing incorrect information could affect my surgical outcome.

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