Resume

Medical Office Cna

Location:

Washington

Posted:

November 08, 2023

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Resume:

Medical and Reproductive History—Infertility Page 1

SRM 5/17

NEW PATIENT HISTORY

Today’s date / / Date of appointment / / PATIENT:

(Legal) Last name: (Legal) First name: Middle initial Age: Date of Birth: / / Preferred Name: Preferred Pronouns: She/Her He/Him They/Them Sex assigned at birth: Female Male

Relationship Status: Single Partnered Married Separated Divorced Widowed Length of Relationship: years

MAILING ADDRESS:

Street: City: State/Providence: Zip/Postal Code: Country: OK to leave message? Best # to reach you:

Cell Phone Number: - Yes No Work Phone Number: -

Yes No

Home Phone Number: - Yes No Email Address: How did you hear about SRM?

Family/Friend

Internet

Radio

Medical office/physician referral (Name of office/physician):

Other Would you like medical notes sent to your other healthcare providers?

Yes

If yes, please indicate which provider(s) you would like us to send medical notes to: Provider Name Address Please indicate provider type: Primary care OB/Gyn Other

DocuSign Envelope ID: F734868F-B91FC312-A1F7B155 D4582 C7C76DE- 73 D6E3-3BC1 839F A60A-B56-47A8-46 456B-D2B 240 1-B36D-98D8 A955 B077-09 83 51947C4D99AF 0ACFCA684556 625A36690689 4D6875E4 6F8F2107 FCA Wa

12 Rose

253-***-****

Rosr

98499

96354

2 02

Ndichu

Lakewood

4711 127th st ct sw apt f22

Medical and Reproductive History—Infertility Page 2 SRM 5/17

Reason for visit: What are your expectations for this visit? What questions do you want answered at this visit? Please fill out the sections that apply to you:

Do you have any theories as to why you have been unable to conceive? List all pregnancies, specifying under outcome whether liveborn, stillborn, ectopic, miscarriage or elective termination

(abortion)

Pregnancy # Preg. Ended

(mo./yr.)

Preg. Length

(weeks, months)

Outcome ( check one )

Present partner Previous partner

Time since contraception last used? How long have you been trying to conceive? If you previously have been pregnant, how long has it been since the most recent pregnancy? Do you have a history of delayed conception with any prior partner? Yes No PREVIOUS FERTILITY EVALUATION:

Have you ever seen a fertility specialist? Yes No Have you had any of the following tests performed? Fertility Test:

Date Result normal? If no, describe:

Yes No Yes No

Semen Analysis / / Antimullerian Hormone / / Day 3 FSH level / / Day 3 Estradiol level / /

FERTILITY HISTORY

Fertility

Never

More than 6years

If I can be able to able to have vhilfren

Get help

Medical and Reproductive History—Infertility Page 3 SRM 5/17

Progesterone level(s) / / Thyroid blood test / / Prolactin blood test / / Blood Type / / Hysterosalpingogram (HSG) / / Antral Follicle Count (AFC) / / Have you had genetic screening for

autosomal recessive disorders?

/ / PRIOR TREATMENTS: (check all that apply)

Treatment #of

cycles

Dates: (mo./year) to

(mo./year)

Outcome

(baby, miscarriage, etc.)

Intrauterine inseminations (no medication):

from: / to: /

Clomiphene/Clomid- dose per day

with timed intercourse

with intrauterine inseminations

from: / to: /

Letrozole/Femara- dose per day

with timed intercourse

with intrauterine inseminations

from: / to: /

Gonadotropins (Follistim, Gonal F, Menopur)

with intrauterine inseminations

from: / to: /

Acupuncture

from: / to: /

Chinese Herbs

from: / to: /

Complete in vitro fertilization (IVF) cycle(s):

1. # eggs # fertilized

# transferred # frozen

2. # eggs # fertilized #

transferred # frozen

3. # eggs # fertilized

# transferred # frozen

from: / to: /

Medical and Reproductive History—Infertility Page 4 SRM 5/17

Frozen embryo transfers:

1. #embryos transferred

2. #embryos transferred

3. #embryos transferred

Canceled in vitro fertilization attempt(s)

from: / to: /

MENSTRUAL HISTORY:

Age when you had your first menstrual period: years old The first day of your most recent menstrual period: / / Menstrual cycle pattern without hormones or oral contraceptive pills (OCP’s) - (check all that apply):

Regular periods Irregular periods No periods

Spotting between periods Heavy periods Light periods How many days from the first day of one period to the first day of the next? days How many days of bleeding do you usually have? days Do you need medication to bring on a period? No Yes If yes, what type? Do you have cramping or pelvic pain with your periods? (check one)

Always Sometimes Recently In the past No Degree of pain (1 to 10, with 10 being most severe): Over the past few years, is the pain: getting better getting worse staying the same If you do not have periods, at what age did you stop having them? years old When was your last Pap smear? / Was it normal? Yes No Have you ever had an abnormal Pap smear? Yes No If “Yes,” date and treatment: Have you ever had a mammogram? Yes No If yes, when was the last one? / Was your mammogram normal? Yes No

GYNECOLOGIC HISTORY

2/16

2015

2 16

4-5

None

Medical and Reproductive History—Infertility Page 5 SRM 5/17

CONTRACEPTIVE METHOD HISTORY:

Type Years Used

Birth Control Pill / Patch

Depo-Provera

Nuva Ring

Norplant/Nexplanam

Diaphragm

IUD

Condoms

Tubal Sterilization

Vasectomy

Rhythm (natural method)

Other

(IF APPLICABLE):

How many times per week do you have intercourse? Any pain with intercourse? Yes No

Do you regularly use lubricant with intercourse? Yes No If yes, what type? Have you used ovulation predictor kits? Yes No If yes, do they work? Do you track your cycles? Yes No If yes, how (App, BBT)? Have you ever had any of the following infections? (please check all that apply)

Chlamydia Gonorrhea Herpes Genital Warts

Trichomonas HIV HPV Hepatitis

Tuberculosis (TB) Other:

Have you ever had pelvic inflammatory disease? Yes No If yes, when? Were you hospitalized? SEXUAL HISTORY

None

4 days

Medical and Reproductive History—Infertility Page 6 SRM 5/17

GENERAL MEDICAL HISTORY

Have you and/or your partner traveled to a country, territory, or city where there has been active Zika virus transmission in the last 6 months? If so, please specify place(s) and dates. Are you and/or your partner planning travel to a country, territory, or city where there has been active Zika virus transmission? If so, please specify place(s) and dates. What is your current weight? Height? Usual weight? Recent weight loss or gain in the past 6 months? Approximately how much did you weigh at age 18? Heaviest lifetime weight?

If applicable, have you been successful with weight loss in the past? How? Do you have any medical problem(s)? Yes (Please list type, dates, and treatments) No 1. 2. 3. 4. 5. Have you had any surgeries? Yes (Please list in chronological order) No 1. 2. 3. 4. 5. Did you have any problems with anesthesia? Yes (Please describe) No REVIEW OF SYSTEMS:

General:

Recent weight gain or loss

Anorexia/bulimia

Lack of energy

Fever/Chills

Other

None

Head, Eyes, Ears, Nose, and

Throat:

Dizziness

Headaches

Loss of sense of smell

Chronis nasal congestion

Blurred vision

Ringing ears

Hearing loss/deafness

Other

None

Respiratory:

Shortness of breath

Asthma

Bronchitis

Pneumonia

Tuberculosis

Other

None

190

199

Lbs

Medical and Reproductive History—Infertility Page 7 SRM 5/17

Please explain any positive responses:

Endocrine/Hormonal:

Diabetes

Hair loss

Thyroid gland problems

Rapid weight gain or loss

Excessive hunger/thirst

Temperature intolerance:

hot flashes or feeling cold

Other

None

Breasts:

Discharge

Lumps

Pain

Cancer

Abnormal mammogram

Other

None

Neurological Problems:

Weakness/Loss of balance

Seizures/Epilepsy

Headaches

Migraine headaches

Numbness

Other

None

Gastrointestinal:

Nausea/Vomiting

Ulcers

Hepatitis

Diarrhea

Blood in your stools

Constipation

Irritable Bowl Syndrome

Other

None

Genito-Urinary:

Bladder infections

Kidney infections

Vaginal infections

Frequent Urination

Leaking urine

Blood in urine

Other

None

Skin/Extremities:

Unexplained rash/inflammation

Acne

Skin cancer

Burn injury

Moles changing in appearance

Excess hair growth

Other

None

Musculoskeletal:

Unusual muscle weakness

Decreased energy/stamina

Other

None

Hematologic:

Blood clotting disorder

Thrombophlebitis

Easy bruising

Swollen glands/lymph nodes

Blood transfusions

Other

None

Cardiovascular:

Palpitations/skipped beats

Chest pain

Murmurs

High blood pressure

Rheumatic fever

Mitral valve prolapse

Other

None

Mental Health Problems:

Depression

Anxiety disorder

Schizophrenia

Other

None

Medical and Reproductive History—Infertility Page 8 SRM 5/17

MEDICATIONS INCLUDING: VITAMINS / HERBS / OVER THE COUNTER MEDICATION (OTC’S) Please list all medications or treatments you are currently taking: Medication Dosage Frequency Reason

ALLERGIES:

Latex? Yes No If yes, specify reaction: Iodine? Yes No If yes, specify reaction: Medications? Yes No Which meds, specify reaction:

SOCIAL HISTORY

Current Occupation: Prior Occupation(s): Have you or do you use any of the following?

Never

Not in the

last 3 months Yes

List amount, type and frequency

(how often-per day / per week)

Tobacco

Marijuana

Alcohol

Social drugs

Caffeine

Exercise

Describe your diet: How many hours of sleep per night do you get on average? DocuSign Envelope ID: F734868F-B91FC312-A1F7B155 D4582 C7C76DE- 73 D6E3-3BC1 839F A60A-B56-47A8-46 456B-D2B 240 1-B36D-98D8 A955 B077-09 83 51947C4D99AF 0ACFCA684556 625A36690689 4D6875E4 6F8F2107 FCA N/a

Regular

N/a

N/a0t

N/a

Cna

Medical and Reproductive History—Infertility Page 9 SRM 5/17

List any significant occupational or other exposures: EMOTIONAL STATUS:

On a scale of 1 to 10, (10 being the highest) what do you estimate your average level of stress to be? Do you feel safe at home and in your relationships? Yes No PERSONAL AND FAMILY GENETIC HISTORY

Are there any known genetic diseases or conditions that run in your family? Yes No If yes, which one(s) and whom? Are you adopted? Yes No

Are you and your partner related? Yes No

Are you of the following ethnic backgrounds? Please check all that apply.

Asian (Chinese, Japanese, Filipino, Indian)

Mediterranean

Middle Eastern

Ashkenazi Jewish

African

Hispanic or Caribbean

French Canadian or Cajun

Caucasian

Have you ever had genetic testing? Yes (Please explain below) No Please indicate which of the following conditions may be found in your family: MEDICAL

PROBLEM Yourself PARENT(S) SIBLING (S)

MATERNAL

GRANDPARENT(S)

PATERNAL

GRANDPARENT(S)

YOUR OTHER

Children Relatives

Autoimmune disorder, such as lupus or

rheumatoid arthritis

Birth defects requiring surgery (cleft lip,

etc)

Bleeding disorders (hemophilia, etc.)

Blindness

Bone disorders

Cancer before age 50 (specify)

Chromosome Problems (Down

syndrome, Klinefelter syndrome)

Clotting disorders (Factor V Leiden,

etc.)

Cna

Medical and Reproductive History—Infertility Page 10 SRM 5/17

Deafness

Developmental delay, autism spectrum

disorder, or learning disabilities

Diabetes (Insulin dependent)

Endocrine Disorders (adrenal gland,

parathyroid, thyroid disorders, Adrenal

Hyperplasia)

Epilepsy (seizures)

Heart defects (“hole in the heart”, etc)

Heart Disease

High Blood Pressure

High Cholesterol

Hydrocephaly (“water on the brain”)

Kidney Disease

Limb defects (missing or extra fingers,

toes, shorten arms or legs)

Marfan Syndrome

Menopause before age 40

Mental Illness (schizophrenia, bipolar,

etc)

Multiple miscarriages

Muscular Dystrophy

Neurofibromatosis

Neurologic or neurodegenerative

diseases (Alzheimer, Huntington, etc)

Neuromuscular diseases (muscular

dystrophies, etc.)

Polycystic Kidney disease

Stillbirth or children who have died as

infants

Stroke

Thalassemia (Cooley’s anemia)

Unusual genitals

Urinary Tract abnormalities

Other serious health issues

Do you have any other family history concerns you would like to discuss? DocuSign Envelope ID: F734868F-B91FC312-A1F7B155 D4582 C7C76DE- 73 D6E3-3BC1 839F A60A-B56-47A8-46 456B-D2B 240 1-B36D-98D8 A955 B077-09 83 51947C4D99AF 0ACFCA684556 625A36690689 4D6875E4 6F8F2107 FCA X

Certificate Of Completion

Envelope Id: DC7C76DE6B56456BB0774D6875E41FCA Status: Completed Subject: Please DocuSign SRM Medical History

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ad0yl3@r.postjobfree.com

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2/14/2023 4:19:46 PM

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ad0yl3@r.postjobfree.com

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Rose Ndichu

ad0yl3@r.postjobfree.com

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