-Age:___
-Gravidity, parity, pregnancy outcomes:____
-Any pregnancy associated complications? : None
-Cycle length and characteristics: _______
-Dysmenorrhea (onset and severity)? : None
-Coital frequency:_____
-Sexual dysfunction?: No
-Duration of infertility:____
-Any previous infertility evaluation and treatment? (if so, results): None
-PMH (past and current):____
-Episodes of PID or STIs:_____
-PSH: No hx of gyne and intra-abdominal surgeries.
-Last Pap Smear (date & results):_____
-SH: Denies tobacco, alcohol, illicit drugs use, and stress. Occupation is:____
-FH: Denies a family history of infertility, birth defects, CF, genetic mutations, mental retardation, early menopause or reproductive failure.
-Pertinent negatives: Patient denies symptoms of thyroid disease, pelvic or abdominal pain, galactorrhea, hirsutism, dyspareunia, vaginal or cervical abnormality, secretions or discharge. She also denies a history of PID, STIs, XRT / chemo. No previous abnormal pap smears.
-Current medications (including herbal/OTC/Vitamins):____
-Allergies to meds:____
Reference
Clinical Gynecologic Endocrinology and Infertility by Marc Fritz, MD, Leon Speroff, MD