Appointment Form

PLEASE COMPLETE THE FOLLOWING FORM INCLUDING THE MEDICAL HISTORY SECTION. UPON RECEIPT OF THIS FORM, YOU WILL BE CONTACTED TO SCHEDULE AN APPOINTMENT.

New Patient Appointment Form

General Information

Female Patient Name

Maiden Name (If applicable)

Full Postal Address

Date Of Birth

Nationality

PPS Number

DPS Number

Home Telephone

Ok To Leave A Message?

Work Telephone

Ok To Leave A Message?

Mobile telephone

Mobile telephone Ok To Leave A Message

Personal Email Address

Occupation

Known Allergies

GP Name

GP Address

Do You Have A Medical Referral To Sims?

Name Of Referring Doctor

If you Were Not Referred By A Doctor Please State How You Heard Of Sims Clinic

Do You Have Health Insurance?

Insurance Company

Name Of Subscriber

Membership Number

Membership Plan

Your Partner

Partner's Name

Partner's Sex

Partner's Date Of Birth

Partner's Home Telephone

Ok To Leave A Message?

Partner's Work Telephone

Ok To Leave A Message?

Partner's mobile telephone

Ok To Leave A Message?

Partner's Personal Email Address

Partner's Occupation

Partner's Known Allergies

Partner's GP Name

Partner's GP Address (Full Postal Address)

Female Patient Medical History

Please complete this form to the best of your knowledge. If there are any question you are uncertain about, do not worry. The details will be discussed with the doctor at the first appointment. The form will take some time to complete. if you have any questions or queries, please do not hesitate to contact us.

If you have further information, medical records or otherwise, please bring them to the first appointment so that your doctor can review them.

Have you ever undergone an operation? (If so, please give details including the year).

Operation 1

Operation 2

Operation 3

Are you currently on any medications?

How long have you been trying to conceive?

Have you used contraception before?

Are you currently attending a medical doctor or being treated for an illness or medical condition?

Have You Had Any Illnesses Or Been Treated For A Medical Condition In The Past

Do You Have An General Medical Complaints At Present

Are You Currently Using Any Non Fertility Medication

Have You Ever Had Any Problems In Any Of The Following Areas Endocrine
Sexually Transmitted Disease
Respiratory
Infectious Disease
Cardiovascular
Gastrointestinal
Renal
Musco-Skeletal
Nervous
Other

Do You Suffer From Any Known Allergies

Have You Ever Reacted To Any Of The Following Substances Penicillin
Voltarol
Latex
Other

Other Please list

Social History

If you smoke how many cigarettes do You smoke per day?

If you are no longer a smoker when did you give up smoking?

If you drink alcohol how many units do you consume per week?

Do you or have you taken any form of recreational drugs?

Where have you recently travelled to? (last six months)

Have you ever travelled to or into an area known to be high medical risk for any infectious disease?

Family History

Has a member of your immediate family died from a chronic illness or disease?

Are there any significant inherited diseases or genetic conditions in your family that you are aware of?

Menstrual History

At what age did you get your first period?

Do you get mid-cycle discomfort or vaginal mucus at your fertile time (ovulation)?

Do you use a pad or a tampon or both?

Do You Get Clots With Your Period?

Are your periods excessively heavy or painful? If they are painful, what painkillers do you take?

Do you notice bleeding between periods?

How often do your periods come?

How long do they generally last?

Date of Last Menstrual period?

Gynaecology History

Have you had any cervical procedures performed?

Do you have any concerns about your sexual life?

Do you experience bleeding after sex?

Do you experience any pain during sex?

Have you suffered from any of the following gynaecologic conditions? Dysmenorrhoea
PMS
Deep Dyspareunia
Chronic Pelvic Pain
Intramenstrual Bleeding
PCO or PCOS
Recurrent Vaginal Bleeding
Endometriosis
Pelvic Infection / Sexually Transmitted Disease
Other

When Was Your Last Pap Smear Result

Have You Had Any Previous Abnormal Pap Smears

Obstetric History

Have Been Pregnant Before

If the answer is yes, please provide any information you can below.

Number Of Pregnancies

Number Of Deliveries

Number Of Live Births

Number Of Term Pregnancies3842 Weeks

Number Of Preterm Pregnancies

Number Of Ectopic Pregnancies

Number Of Spontaneous Abortions

Number Of Therapeutic Abortions

Number Of Still Births

Number Of Neonatal Deaths

Pregnancy 1

Pregnancy1 Gestational Age Weeks

Pregnancy1 Pregnancy Outcome

Pregnancy1 Mode Of Delivery

Pregnancy1 Delivery Outcome

Pregnancy1 Other Any Complications

Pregnancy 2

Pregnancy2 Gestational Age Weeks

Pregnancy2 Pregnancy Outcome

Pregnancy2 Mode Of Delivery

Pregnancy2 Delivery Outcome

Pregnancy2 Other Any Complications

Pregnancy 3

Pregnancy3 Gestational Age Weeks

Pregnancy3 Pregnancy Outcome

Pregnancy3 Mode Of Delivery

Pregnancy3 Delivery Outcome

Pregnancy3 Other Any Complications

Pregnancy 4

Pregnancy4 Gestational Age Weeks

Pregnancy4 Pregnancy Outcome

Pregnancy4 Mode Of Delivery

Pregnancy4 Delivery Outcome

Pregnancy4 Other Any Complications

Pregnancy 5

Pregnancy5 Gestational Age Weeks

Pregnancy5 Pregnancy Outcome

Pregnancy5 Mode Of Delivery

Pregnancy5 Delivery Outcome

Pregnancy5 Other Any Complications

Previous Treatment

Have You Had Previous Fertility Treatment

If Yes Please Provide As Much Information As You Are Able To

Treatment 1

Treatment1 Date

Treatment1 Treatment Type

Treatment1 Drugs Days

Treatment1 Follicles Eggs

Treatment1 Injected Fertilised

Treatment1 Number Of Embryos Transferred

Treatment1 Embryo Day Quality

Treatment1 Number Day Frozen

Treatment1 Outcome

Treatment1 Comments

Treatment 2

Treatment2

Treatment2 Date

Treatment2 Treatment Type

Treatment2 Drugs Days

Treatment2 Follicles Eggs

Treatment2 Injected Fertilised

Treatment2 Number Of Embryos Transferred

Treatment2 Embryo Day Quality

Treatment2 Number Day Frozen

Treatment2 Outcome

Treatment2 Comments

Treatment3

Treatment3 Date

Treatment 3

Treatment3 Treatment Type

Treatment3 Drugs Days

Treatment3 Follicles Eggs

Treatment3 Injected Fertilised

Treatment3 Number Of Embryos Transferred

Treatment3 Embryo Day Quality

Treatment3 Number Day Frozen

Treatment3 Outcome

Treatment3 Comments

Treatment 4

Treatment4

Treatment4 Date

Treatment4 Treatment Type

Treatment4 Drugs Days

Treatment4 Follicles Eggs

Treatment4 Injected Fertilised

Treatment4 Number Of Embryos Transferred

Treatment4 Embryo Day Quality

Treatment4 Number Day Frozen

Treatment4 Outcome

Treatment4 Comments

Treatment5

Treatment 5

Treatment5 Date

Treatment5 Treatment Type

Treatment5 Drugs Days

Treatment5 Follicles Eggs

Treatment5 Injected Fertilised

Treatment5 Number Of Embryos Transferred

Treatment5 Embryo Day Quality

Treatment5 Number Day Frozen

Treatment5 Outcome

Treatment5 Comments

Male partner Medical History (If Applicable)

Are You Currently On Any Medications?

Do You Have Any General Medical Complaints At Present

Have You Had Any Illnesses Or Been Treated For Any Medical Condition In The Past

Are You Currently Attending A Medical Doctor Or Being Treated For A Medical Condition

Fertility / Andrology

Have You Ever Had A Semen Analysis Carried Out

If Yes What Was The Result

Have You Been Responsible For Any Pregnancies In The Past Number

Have You Ever Experienced A Groin Injury Or Undergone Groin Surgery

Have You Any History Of Operations Involving The Reproductive System

Do You Have Undescended Testicles

Did You Ever Have Mumps

If Yes Was This As A Child Or An Adult

Male Partner: Do You Have Any Concerns About Your Sexual Life

Social History

Male Partner: If you smoke how many cigarettes do you smoke per day?

Male Partner: If you are no longer a smoker, when did you give up smoking?

Male Partner: If you drink alcohol, how many units do you consume per week?

Do you or have you taken any form of recreational drugs?

Where have you recently travelled to? (Last Six Months)

Have you ever travelled to/into an area known to be high medical risk for any infectious disease?

Surgical History

Have you ever undergone an operation? If so please give details:

Operation 1

Operation 2

Operation 3

Male Partner: Have you ever had any problems in any of the following areas? Endocrine
Sexually Transmitted Disease
Respiratory
Infectious Disease
Cardiovascular
Gastrointestinal
Renal
Musco-Skeletal
Nervous
Other

Male Partner: Do you suffer from any known allergies?

Male Partner: Have you ever reacted to any of the following substances? Penicillin
Voltarol
Latex
Other

Male Partner: Has a member of your immediate family died from a chronic illness or disease?

Male Partner: Are there any significant inherited diseases or genetic conditions in your family that you are aware of?

Additional Comments

Your records are considered confidential and will not be released without your consent and signature.

I hereby authorise the Sims Fertility Clinic to release information to my GP and myself.

Please indicate Yes or No

Spam Prevention

In order to submit this form successfully, you must complete this question

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Useful Resources

Open Day

Fertility and Infertility

How to improve your chances of conception

Sunday, 16 September 2012

10am - 1pm

Dr Anthony Walsh

The history of Sims. Watch the video >

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Take a look inside our Clinic

We are an Academic Unit providing teaching for the students of the Royal College of Surgeons in Ireland.

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Clonskeagh Road, Clonskeagh, Dublin 14.
Tel: +353 01 2080710, Fax: + 353 1 2080715
Email: info@sims.ie
Sims International Fertility Clinic is authorised by Irish Medicines Board as a Tissue Establishment (TE-011)

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Appointment Form

General Information

Your Partner

Female Patient Medical History

Social History

Family History

Menstrual History

Gynaecology History

Obstetric History

Pregnancy 1

Pregnancy 2

Pregnancy 3

Pregnancy 4

Pregnancy 5

Previous Treatment

Treatment 1

Treatment 2

Treatment 3

Treatment 4

Treatment 5

Male partner Medical History (If Applicable)

Fertility / Andrology

Social History

Surgical History

Additional Comments

Spam Prevention

Useful Resources

Useful Resources

Open Day

Fertility and Infertility

Dr Anthony Walsh

Website Design by Webtrade.ie

© 2012 Sims IVF