tailieunhanh - THE JOHNS HOPKINS HOSPITAL DIVISION OF REPRODUCTIVE ENDOCRINOLOGY

Women usually produce one mature egg per menstrual cycle. Because IVF is so expensive, current clinical practice is to give women hormonal drugs to stimulate multiple eggs in one cycle, to increase their chances of pregnancy. For this process, women inject three different hormones over the course of four to six weeks to “shut down” their ovaries, “hyperstimulate” them, and to control the timing that the mature eggs will be released. This is followed by a surgical procedure under light anesthesia, in which an ultrasound-guided needle is inserted through the vaginal wall into the ovary and the eggs are suctioned. | Your Name THE JOHNS HOPKINS HOSPITAL DIVISION OF REPRODUCTIVE ENDOCRINOLOGY Please take the time to fill out the following questionnaire If the reason of your visit is related to Infertility or Recurrent Miscarriage in addition to part A please fill parts B and C of the form If you are here for any other reason please fill only part A. Your Name Age Birth date Address __ City State Zip Code Telephone home work Your Occupation Your Employer Your Religion Ethnic background Spouse s Name if applicable _ Spouse s Occupation Date of Marriage if applicable Physician whom you will be seeing Date of visit Person who referred you _ Reason for your clinic visit __ 1 Your Name Part A Please describe the background of your present problem. Include all symptoms how long you have experienced them and indicate whether they have changed in severity over time. Gynecological History Menstrual History What were the dates of your last two menstrual periods At what age did you begin to menstruate What is the average length of your menstrual cycle Interval from 1st before bleeding of the next cycle Are you normally regular or irregular circle one If irregular please describe How many days do you bleed day of period until day Do you have pain during periods Do you have any pain between periods If so describe Yes No Yes No circle one circle one Do you bleed between periods If so describe frequency and amount of blood loss Yes No circle one When was your last Pap smear __ Have you ever been treated for an abnormal Pap smear Yes No circle one If so how _ Have you ever had a mammogram Yes No circle one If so when was your last study _ 2 Your Name Sexual History Are you currently sexually active Frequency of intercourse times week or Yes No times month circle one N A Do you bleed during or .