| Doctor's Name: |
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| Doctor's Phone: |
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| Date of Diagnosis: |
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| Stage: |
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| Size: | |
| Histologic Grading: | |
| Histologic Type: | |
| Nuclear Grading: | |
| Estrogen Receptor: |
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| Mitotic Index: | |
| Progesterone Receptor: |
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| Vascular Invasion: |
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| Her 2 Neu Positive: |
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| Lymph Node: | |
 |
| Have you been/will you be tested for BrCA1 and BrCA 2 genes? |
|
No, I will not be |
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Yes, I will be |
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Test pending |
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Both negative |
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Only BrCA1 positive |
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Only BrCa2 positive |
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Both positive |
If there were any positives, what are the official results?
Will you send us a copy of the official report? |
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Have you ever received chemotherapy and/or radiotherapy for cancer? |
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Yes |
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No |
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| If yes, provide the type, including name, dose, frequency, number of treatments, and/or radiation treatments. |
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| If yes, provide duration of treatment including start and end dates and note any complications. |
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Have you taken Zoladex(GnRh analogue) while you were receiving chemotherapy and/or radiotherapy? |
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Yes |
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No |
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| If yes, provide the duration and dates. |
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Ovarian Function |
| (please answer the following questions to help us evaluate your ovarian function) |
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| Are you still menstruating? |
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Yes |
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No |
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| Are your menstrual periods regular? |
| Yes |
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No |
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| If they have become irregular, when did this happen? |
|
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| Did your menstrual periods stop or become irregular while you were receiving chemo? |
| Yes |
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No |
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| If yes, did they return to normal? |
|
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| If returned to normal, when? |
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| If they have stopped for 3 or more cycles, when was your last menstrual period? |
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| If your menstrual periods stopped and then returned, is the pattern the same as it once was? |
| Yes |
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No |
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| How many days between the 1st day of one menstrual period and the 1st day of the next one? |
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| Describe the amount of bleeding? |
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| How many pads/tampons are you using each day? |
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| How many days is your menstrual period? |
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| Have you been told you have become "menopausal" by any physician? |
Yes
No
|
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| If yes, did they perform any tests and what tests? |
|
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| Can we obtain those medical test records? |
Yes
No |
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| Would you be willing to undergo ovarian reserve testing to see where you stand? This would require a blood test. The blood can be drawn at our center at no cost to you; otherwise, we can fax a requisition, but it may/may not be covered by your insurance. |
Yes |
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No |
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Fertility History |
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| Have you ever been pregnant? |
| Yes |
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No |
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| If yes, please list outcome(s): |
|
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| Have you ever been diagnosed with infertility? |
| Yes |
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No |
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| If yes, what was the diagnosis, and when was it? |
|
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| Have you ever received fertility treatment? |
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Yes |
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No |
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| If yes, what was the outcome? |
|
|
| Have you ever received an egg donation? |
| Yes |
|
No |
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| If yes, when? |
|
|
| Ever used a surrogate? |
| Yes |
|
No |
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| If yes, when? |
|
|
| Ever been pregnant after chemotherapy? |
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Yes |
|
No |
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| If yes, what was the outcome? |
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| Liveborn infant? |
| Yes |
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No |
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What gestational age was reached?
(number of weeks of pregnancy) |
|
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| Was there any pregnancy complication(s): |
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Yes |
|
No |
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| If yes, explain the pregnancy complication. |
|
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| High blood pressure or pre-eclampsia? |
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Yes |
|
No |
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| Gestational Diabetes? |
| Yes |
|
No |
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| If Gestational Diabetes, did you require insulin? |
| Yes |
|
No |
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| Was there any birth complication? |
| Yes |
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No |
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| If yes, please explain birth complication. |
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| What was the Neonatal outcome. |
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| What was the Apgar Score at 1 minute. |
|
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| What was the Apgar Score at 5 minutes. |
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| What was the weight. |
|
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| Was there a Neonatal ICU stay? |
| Yes |
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No |
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| Number of days for the Neonatal ICU stay. |
|
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| Explain the procedures. |
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