Doctor’s notes

Lori Arnold, M.D., F.A.C.O.G
Reproductive Endocrinology and Fertility

Date this form completed _________________ Your name: ________________________________________ Partner’s Name: _____________________________________ Age _______________ Birth date __________________ Height _________________ Weight ________________________ How long have you been trying to get pregnant? _______________________________ Have you previously been pregnant? ___________________________ Have you previously tried to get pregnant? ______________________ Reason for your visit today? ________________________________________________________________________________ ________________________________________________________________________________________________________ B. PREGNANCY HISTORY Times pregnant _________ Term births _________ Premature births _________ Miscarriages ___________ Elective abortion __________ Adopted children __________
Outcome (miscarriage, abortion, ectopic, vaginal delivery, cesarean section, stillbirth, complications Fifth
Comments: ______________________________________________________________________________________________
Contraceptive Use

Menstrual (hormonal) history
Date your last menstrual period began _________________________________________________________________
Your age at your first period ________________________________________________________________________
Are your periods regular? ___________________________________________________________________________
How many days from onset to onset? _________________________________________________________________
How many days does your period last? ________________________________________________________________
Do you bleed between periods? _____________________________________________________________________
Do you have premenstrual symptoms  almost always  rarely  never
Have you ever needed medication to bring on your period? Yes 
If yes, what medication: _________ _______________ When? ____________________________________ If you have a hormonal disorder, please specify and treatment _____________________________________________
Pelvic pain/cramps:  none  during your period  before your period  after your period
 at mid-cycle  during intercourse  with urination  with bowel movements
 cause you to miss usual activities  cause you to miss work
Pelvic cramps/pain are:  mild  moderate  severe  getting worse  improving
 not changing  on the right side  on the left side  in the middle
What medications do you take for pain/cramps? _________________________________________________________
Do you have painful intercourse:
If you answered yes to any questions, please explain ______________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Gynecologist: _______________________________________________________________________________________ Primary Care Physician: ________________________________________________________________________________ Last Pap smear _________________ Any abnormal Pap smears? ___________, dates _______________________ If yes, explain: __________________________________________________________________________________________ How many times per week do you have sexual intercourse? How many times do you have intercourse around ovulation?
Past Medical History
If yes, explain _______________________________________________________________________________________ List all serious or chronic illnesses or injuries not already described _____________________________________________ Medications: Please list all prescriptions and over-the-counter drugs used during the past year.



To what (drug or substance)?

Operations and Hospitalizations

H. FEMALE FAMILY HISTORY Ethnic background (circle): African/American Comments: __________________________________________________________________________________________ H. SOCIAL HISTORY Cigarettes – packs smoked/day _______________________________________________________________________ Alcohol – type and number of drinks/week ______________________________________________________________ Marijuana – amount ________________________________________________________________________________ Other drugs – type and amount _______________________________________________________________________ Ever used intravenous drugs? _________________________________________________________________________ How much do you exercise? __________________________________________________________________________ Comments: ___________________________________________________________________________________________ I. PREVIOUS EVALUATION Have you had: Abnormal
(if known)

Basal body temperature (BBT)
(if known)
Comments: ___________________________________________________________________________________________ K: PREVIOUS TREATMENT Approx dates
Approx dates
Please use the remainder of this page to explain any additional information you think the doctor may need.


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