fertility preservation

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fertility preservation

Fertility Preservation - Progress Notes
Please take time to accurately complete the online application.
First Name:   *
Last Name:   *
Address 1:
Address 2:
City:
Zip:
Home Phone:
Daytime Phone:   *
email:   *
Retype email:
Please indicate which doctor referred you:
Doctor's Name:
Doctor's Phone:
Doctor's Fax:
Doctor's Email:
Other referral source:
If accepted as a patient, when would you want our services to begin:
   Immediately
  Starting as of      (mm/dd/yyyy)
What is the main reason you wish to see Dr. Oktay?

Personal Characteristics

Height:
Weight:
Enter Weight:    lbs
Age:
Enter BirthDate:   e.g. 1973-01-25
Enter Age:   Years

Personal Health History:

Do you have any allergies that you're aware of?
  Yes
  No
If yes, please indicate what you are allergic to:
Are you allergic to any medications?
  Yes
   No
If yes, please tell us what medication you're allergic to:
Were you or any of your relatives born with genetic disorders?
  Yes
  No
Do you have any dietary restrictions?
  Yes
   No
If yes, what are your dietary restrictions, and for what reason?
Do you take any supplemental vitamins or herbal remedies on a continual basis?
  Yes
   No
If yes, please list what vitamins or herbal remedies you are taking:
Do you take any prescription or over the counter medication on a regular or continual basis?
  Yes
   No
If yes, please list what medication you are currently taking:
Have you had any surgeries in the past?
  Yes
   No
If yes, please indicate what surgeries you have had:
Have you ever had an adverse reaction to general anesthetics?
  Yes
   No
If yes, please indicate what happened, and the severity of the response:
Have you ever been hospitalized for anything other than the above listed surgeries?
  Yes
   No
If yes, please tell us why you were hospitalized:

Menstrual History:

(please answer the following questions about your menstrual cycle)
How old were you when you first began to menstruate:
   10
   11
   12
   13
   14
   15
   Other        Enter Other:  
How many days are there (usually) between one period to the next?
   26-28
   29-32
   Other        Enter Other:  
How many days do your periods usually last?
   2-3
   4-5
   6-8
   Other        Enter Other:  
Do you ever experience mid-cycle bleeding?
  Yes
  No
Would you describe your menstrual cycle as:
  Regular
  Irregular
In general, how heavy is your menstrual flow?
  Light
  Moderate
  Heavy
  Very Heavy

Sexual Activity/History:

(please answer the following questions about your sexual history)
How many sexual partners have you had intercourse with in the past year?
  0
  1
  2
  3
  4 or more
Have you been with a sexual partner that is a known user of drugs?
  Yes
   No
Have you had intercourse with a bisexual or homosexual partner?
  Yes
   No
Have you had intercourse without the use of a condom in the last year?
  Yes
   No
Have any of your past or present sexual partners shown evidence of having HIV infection?
  Yes
   No
Have you ever been with a sexual partner who tested positive for a sexually transmitted disease?
  Yes
   No
If you answered yes to any of the above questions, please explain in full detail:
Have you ever taken, or are you currently taking oral contraceptives?
  Yes
   No
If yes, what brand and for how long?

Cancer History:

Do you have your pathology report?
  Yes
   No
Stage:
Size:
Histologic Grading:
Histologic Type:
Nuclear Grading:
Estrogen Rec:
Mitotic Index:
Progesterone Rec:
Vascular Invasion:
Her 2 Neu Rec:
Lymph Node:
Have you been/will you be tested for BrCA1 and BrCA 2 genes?
No I will not be
Yes I will be
Test pending
Both negative
Only BrCA1 positive
Only BrCa2 positive
Both positive
If tested for BrCA 1 or 2 what was the result?
If you have a family history of cancer, have family members been tested for BRCA 1 or 2?
Have you ever received chemotherapy and/or radiotherapy for cancer?
   Yes
   No
If yes, provide the name and dose of the drugs or radiation treatment,as well as the duration of treatment. what were the complications?
Have you taken Zoladex(GnRh analogue) while you were receiving chemotherapy and/or radiotherapy?
   Yes
   No
If yes, provide the duration and date.
Has there been a change in the regularity of your periods after chemotherapy and/or radiotherapy?
Have you ever been diagnosed as menopausal after chemotherapy and/or radiotherapy?
Will you have chemo and/or radiation in the near future?
   Yes
   No
If yes, provide the name and dose of the drugs or radiation treatment,as well as the pending duration.
Have you ever been told in the past, that you have had any of the following? (check all that apply):
Sexually Transmitted Disease Chlamydia
AIDS Condyloma (Human Papaloma Virus)
Ureaplasma/Mycoplasma Autoimmune Disorder
Syphilis Ovarian Cysts
Multiple Sclerosis Alzheimer's Disease
Tuberculosis Herpes Simplex Virus I or II
Abnormal Pap Smear Cancer
Hepatitis A, B or C Endometriosis
Fibroids Pelvic Inflammatory Disease
Hypertension Endocrine Disease
Have you had a Pap Smear within the past 6 months?
  Yes
  No
Was result of your Pap Smear within normal limits?
  Yes
  No
Have you received a blood transfusion within the past six months?
  Yes
  No
Have you ever received a blood transfusion or other blood products at any time in your life?
  Yes
   No
If yes, when did this happen?
Have you ever received blood products or clotting factors for abnormal bleeding?
  Yes
   No
Have you ever been excluded from blood donation?
  Yes
   No
If yes, please explain when and why:
Have you ever received Pituitary derived growth hormone?
  Yes
  No
Do you certify that your answers and explanations were voluntarily given?
  Yes
  No
Are you aware of any other health problems in your self, family or previous sexual partners that you have not already disclosed?
  Yes
   No
If yes, please indicate those problems you are aware of, that you have not already disclosed to us in this document:

 

I hereby certify that my answers and explanations, which were voluntarily given in this questionnaire, are correct. I understand that the answers used in this questionnaire will be used to help IFP provide their recommendations. I am not aware of any problems in myself, my family that were not answered in the above questions.
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