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Microsoft word - womensqnaireclinical-updated 11-22-08.doc

WOMAN’S INITIAL QUESTIONNAIRE
Natural Procreative Technology Evaluation for Infertility or Miscarriage

TABLE OF CONTENTS

Page 2
Introduction and Purpose of this Questionnaire D. Gynecologic History (Female Sexual Health) H. Previous Fertility-Related Investigations K. Previous Fertility-Related Medical Treatments L. Previous Assisted Reproductive Technology (ART) M. Experience of Past Fertility Treatment (* To avoid confusion with zero, there is no section O.) Introduction and Purpose of the Woman’s Initial Questionnaire

Why you are receiving this questionnaire
You are being given this Woman’s Questionnaire because you have scheduled an initial evaluation for
infertility or miscarriage. This questionnaire comprehensively addresses relevant issues for your evaluation
and treatment. It was designed by physicians working with Natural Procreative Technology.

How this questionnaire will be used
Your physician will use the information from this questionnaire and the separate questionnaire from your
partner to provide important information for the medical evaluation and your desires for treatment. We will
discuss your responses to many of the items in this questionnaire during our initial visit, and subsequent
visits, as needed.
Natural Procreative Technology (NPT, NaProTechnology)
Our approach to evaluating and treating fertility or pregnancy problems is based on Natural Procreative
Technology (NPT, NaProTechnology). During our visits, we will explain to you specific recommendations for
your unique situation. General information about NPT is available at www.reproductiveinstitute.com.
What to bring to your first (or next) visit
Please bring this questionnaire, even if you haven’t finished filling it out.
Please also bring copies of medical records from any previous evaluations or treatments for infertility that
you may have had. In some cases, it may be more convenient for you to mail these items.
It is best if both you and your partner can attend the initial consultation.
Why there are two questionnaires: woman’s and man’s
Our experience has shown that women and men remember and perceive things differently with regard to a
couple’s fertility problems. In addition, some information is specific to the woman or the man.
Sensitive questions
You may skip any question you are uncomfortable answering. If you choose to skip a question, please place
a line through the question rather than leaving it blank. There may be items that you would prefer not to
discuss in front of your partner. If so, you may CIRCLE the question number to tell us that your response to
this question is confidential and that you prefer that this item NOT be discussed with your partner.
Estimated time to complete questionnaire
It is estimated that this questionnaire will take about 45 minutes to complete for most women.
Questions or comments
If you have any questions or comments or feel a question is inappropriate for your situation, please make a
mark or write a comment at the question or at the end of questionnaire. You may also discuss any questions
or comments with your health provider.
Where to return the questionnaire
Please return the questionnaire to your health provider at the time of your next appointment. Alternatively,
you may mail it to your provider.
Option to participate in the iNEST study
Your health care provider may invite you to participate in an ongoing clinical study to assess live birth rates
among those who consider or receive NPT treatment to conceive or maintain pregnancy. This study is
known as the international NaProTechnology Evaluation and Surveillance of Treatment (iNEST). The
purpose of the iNEST study is to understand the use of NPT, and characteristics that may help us predict
how successful NPT can be for each couple for infertility or miscarriage.
Whether or not you participate in the iNEST study will not affect the clinical care that you receive.
When you are asked, you may choose whether or not to participate in the iNEST study. If you participate,
your answers from this questionnaire will be recorded confidentially for the study. If you do not participate, your answers from this questionnaire will not be reported to the study. Natural Procreative Technology Evaluation for Infertility or Miscarriage
Woman’s Initial Questionnaire
MorningStar Family Health Center #11
Couple ID# _____________________________
NPT Physician Name _________________________________

Your Family (Last) Name ___________________________________
Your Given (First) Name ___________________________________
A. Initial Information

(A-01) Today’s Date |___│___| / ___│___│___| / ___│___│___│___| (example: 17 / Mar / 2005)
Day / Month / Year

(A-02) What is your month and year of birth? |___│___│___| / |___│___│___│___| (example: Mar / 1985)
Month / Year
(A-03) What is your marital status? (Please mark
If not married, please skip to question A-06 below; if married, continue to question A-04.

(A-04) In what month and year did you marry? |___│___│___| / |___│___│___│___|
Month / Year
(A-06) How did you learn about Natural Procreative Technology (NPT, NaPro)? (Please mark A friend or acquaintance who had NPT treatment Other, please describe: _________________________________ (A-07) Why have you decided to try NPT? _____________________________________________________________________________________ _____________________________________________________________________________________ (A-08) In order to conceive or maintain pregnancy, have you at any time previously used Natural Procreative Technology (NPT, NaPro)? If yes, in what month and year did you start NPT treatment previously? ________________________ (A-09) Have you ever consulted a different physician for NPT treatment? If yes, please give name of physician_____________________________ (A-10) Have you started medical treatment with NPT? If yes, in what month and year did you start? __________________________ If no, in what month and year do you expect to start? __________________________________ Still undetermined (waiting or considering) (A-11) Have you started charting with the Creighton Model Fertility Care System? If yes, in what month and year did you start? __________________________ If no, in what month and year do you expect to start? __________________________________ Still undetermined (waiting or considering)

B. Trying to Have a Baby
For the purposes of this questionnaire, “trying to have a baby” means having regular sexual intercourse
without any contraception, whether or not you were doing anything else to try to get pregnant.
(B-01) Using this definition, in what month and year did you start trying to have a baby with your partner?
|___│___│___| / |___│___│___│___| (example: Mar / 1985)
Month / Year
(B-02) During the time you have been trying to have a baby, was there any time when you or your partner did something to avoid pregnancy (such as abstinence during fertile days, condoms, withdrawal, or other contraception of any kind) for more than one month? If yes, for how many months total? ________________ (B-03) During the time you have been trying to have a baby, was there any time when you and your partner did not have intercourse for more than one month? If yes, for how many months total? ________________ (B-04) During the time you have been trying to have a baby, how often do you and your partner have intercourse, in general? _____Times per month OR _____Times per week
(B-05) How often do you use lubricants when you have intercourse? (Please mark (B-06) How often is intercourse physically painful for you? (Please mark
C. Menstrual History

(C-01) At what age did you have your first menstrual period? ________ (Age)
(C-02) On average, how many days of menstrual bleeding do you have?
(C-03) In the last year, what is the shortest menstrual cycle you have had (number of days from the beginning of one menstrual period to the next menstrual period)? (C-04) In the last year, what is the longest menstrual cycle you have had (number of days from the beginning of one menstrual period to the next menstrual period)? (C-05) What is the beginning date of your last menstrual period? |___│___| / ___│___│___| / ___│___│___│___| (example: 17 / Mar / 2005)
Day / Month / Year
(C-06) How would you describe your cycles currently? (C-07) Have your menstrual cycles ever stopped for any reason? If yes or unsure, please explain: _______________________________________________________
(C-08) Do you usually have any kind of symptoms for 4 or more days before your menstrual bleeding starts?

If no symptoms experienced for 4 or more days, skip to question C-12 below; if yes, continue to
question C-09.

(C-09) Please indicate which of the following symptoms you have for 4 or more days before your menstrual bleeding starts: (Please mark Other (describe): _________________________________________________________ (C-10) Referring to all the symptoms marked in question D-21, on the whole, how severe would you rate these symptoms? (Please mark (C-11) Are these symptoms relieved with menstruation? (C-12) How painful are your menstrual periods? (Please mark (C-13) Do you suffer from constipation and/or diarrhea at the time of your period?
D. Gynecologic History (Female Sexual Health)

The next questions are about your health history that might affect fertility. Please answer according to your
best recollection.
(D-01) How many sexual partners have you had over your lifetime? ________ (Number)
(D-02) Have you ever had a vaginal yeast infection?
(D-03) Have you ever had bacterial vaginosis? (D-04) Have you ever been diagnosed with vaginal trichomonias? (D-05) Have you ever had a vaginal infection but you are not sure what kind? (D-06) Have you ever been diagnosed with pelvic inflammatory disease or pelvic infection? (D-07) Have you ever been diagnosed with Chlamydia? (D-08) Have you ever been diagnosed with gonorrhea? (D-09) Have you ever been diagnosed with genital warts? (D-10) Have you ever been diagnosed with genital herpes? (D-11) Have you ever been diagnosed with any other sexually transmitted infection? If yes or unsure, please describe: ______________________________________________________ (D-12) Have you ever been tested for any sexually transmitted infection (even if the test was negative)? (D-13) Have you ever had symptoms of menopause such as hot flushes? (D-14) Have you ever had irregular bleeding from the vagina or uterus? (D-15) Have you ever had ovarian cysts? (D-16) What is the month and year of your last Pap smear? __________Month (D-17) Have you ever had an abnormal Pap smear?
If no, skip to question D-19 below; if yes, continue to question D-18.

(D-18) If yes or unsure, what kind of abnormality(ies) were noted on your Pap smear? (Please mark (D-19) Have you ever had surgery or freezing of the cervix (such as CRYO, laser, LEEP, hot cautery)? If yes, which procedure(s)? _____________________________________________________
E. Family Planning History

(E-01) Have you ever used natural family planning (NFP)?
Which NFP method(s)? ______________________________________________________________ Over your lifetime, how long did you use or have you used NFP? ______Year(s) ______Month(s)
What is the date of your last use of NFP? |___│___│___| / |___│___│___│___| (example: Mar / 1985)
Month / Year
Over your lifetime, how long did you use or have you used condoms? ______Year(s) ______Month(s) What is the date of your last use of condoms? |___│___│___| / |___│___│___│___| (example: Mar / 1985)
Month / Year
(E-03) Have you ever used oral contraceptives (birth control pills)? If yes: Over your lifetime, how long did you use or have you used birth control pills? ______Year(s) ______Month(s) What is the date of your last use of birth control pills? |___│___│___| / |___│___│___│___| (example: Mar / 1985)
Month / Year
(E-04) Have you ever used the 3-month contraceptive injection (Depo Provera®)? If yes: Over your lifetime, how long did you use or have you used the contraceptive injection? ______Year(s) ______Month(s) What was the date of your last injection? |___│___│___| / |___│___│___│___| (example: Mar / 1985)
Month / Year
(E-05) Have you ever used any other hormone contraceptives such as Norplant®, a hormone patch, or a hormonal vaginal ring? Please specify name: __________________________________ Over your lifetime, how long did you use or have you used these other hormone contraceptives? ______Year(s) ______Month(s) What is the month and year of your last use of these other hormone contraceptives? |___│___│___| / |___│___│___│___| (example: Mar / 1985)
Month / Year
(E-06) Have you ever used an intrauterine device (also called IUD, IUCD, or “the coil”)? Over your lifetime, how long did you use or have you used an IUD? ______Year(s) ______Month(s) What is the month and year of your last use of an IUD? |___│___│___| / |___│___│___│___| (example: Mar / 1985)
Month / Year
(E-07) Have you ever used emergency contraception (the “morning after pill”)? What is the month and year of your last use of emergency contraception? |___│___│___| / |___│___│___│___| (example: Mar / 1985)
Month / Year
(E-08) Have you ever used any other method(s) of family planning? Please describe any other method(s) used? ______________________________________________ Over your lifetime, how long did you use or have you used any other method(s)? ______Year(s) ______Month(s) What is the date of your last use of any other method(s)? |___│___│___| / |___│___│___│___| (example: Mar / 1985)
Month / Year

F. Pregnancy History

The next questions are about your past pregnancies, if any.
(F-01) How many times have you ever been pregnant, counting all pregnancies, regardless of the outcome?

If you have never been pregnant at all, please skip to question F-03, page 10
If you have been pregnant, please continue on the next page

(F-02) Please complete the chart below as completely as possible for each pregnancy you have ever had. If unsure of dates, please provide your best estimate. (i.e., 12 ML = molar preg. with your pregnancy baby(ies)? # Month/Year Years Months Mo/Day/Yr gestation
Complications
(please indicate which pregnancy number for each comment): __________________________________________________________________
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________ (F-03) Has your current partner ever fathered children with another partner? If yes, what year(s) were they born? ___________________________________________________________________

G. Previous Fertility-Related Efforts

The following questions ask about things you may have done to enhance fertility, either on recommendation
of a doctor, or on your own.
In order to conceive, have you at any time:
Question Answer
(G-01) Timed intercourse by counting the number of days in your (G-02) Taken your basal body temperature? (G-03) Used urine LH test kits (urine ovulation test kits)? (G-04) Taken herbs intended to enhance fertility? (G-05) Taken vitamins intended to enhance fertility? (G-06) Monitored vaginal discharge, cervical mucus, or cervical fluid?
H. Previous Fertility-Related Investigations

Questions H-01 through H-11 are found on the next page.
Date of Most
Question Answer
Recent Test
(Month/Year)
(H-01) Have you had an ultrasound of the (H-02) Have you had an ultrasound scan of the ovaries to look at ovulation (follicle (H-03) Have you had a hysterosalpingogram (x-ray assessment of (camera visualization of uterine cavity)? (H-06) Have you had a D&C (scraping of (H-07) Have you had a post-coital test (looking at sperm taken from your cervix (H-08) Have you had day 3 or early cycle (H-09) Have you had day 21 or late cycle blood tests (progesterone or ovulation)? (H-11) Have you had any other investigations? If yes, please describe: ____________________________________________________________________________________________
I. Previous Fertility-Related Diagnoses

Please mark
all that you or your partner have ever been told you have or suspect that you might have: (I-02) Unexplained recurrent miscarriage (I-09) Hostile or limited cervical mucus (I-11) Blocked or damaged fallopian tubes (I-14) Luteinized unruptured follicle (LUF) (I-15) Male factor infertility or sperm abnormality If yes, please specify: _______________________________________________________________
J. Previous Fertility-Related Surgeries

(J-01) Which of the following surgeries have you had? Please include month and year of the surgery.
Date(s) of Surgery
Diathermy, cautery, or laser treatment for endometriosis
Ovarian diathermy, cautery, or drilling for polycystic ovaries
Laparotomy (major abdominal or pelvic surgery) Ovarian Cystectomy (removal of ovarian cyst) (J-02) Have you ever had any surgery in the pelvis or reproductive organs that was not described above? If yes, please describe: ______________________________________________________________ (J-03) Have you ever had any other surgery anywhere in the body that was not described above? If yes, please describe: ______________________________________________________________ _________________________________________________________________________________

K. Previous Fertility-Related Medical Treatments

(K-01) Have you taken clomiphene?
(Clomiphene is sold in different countries under different brand names, including: Clomid, Serophene,
Milophene, Ardomon, Clom, Clomifene, Clomifeno, Clomifenum, Clomiphene Citrate, Clomipheni,
Clomipheni Citrate, Clomivid, Clostilbegyt, C-ratioph, Dufine, Dyneric, Fertomid, Gravosan, Indovar,
Klomifen, Kyliformon, Omifin, Pergotime, Phenate, Pioner, Prolifen, Serpafar, Tokormon.)
If no, please skip to question K-09 on the next page; if yes, continue to question K-02.

(K-02) For how many cycles have you taken clomiphene?
(K-03) What is the maximum dose you have taken per day? (Note: One tablet = 50 mg)
(Please mark
(K-04) What is the number of days you took this dose? (Please mark (K-05) Did you take anything along with the clomiphene to enhance mucus? If yes, what medication did you take? ____________________ (K-06) Was the treatment with clomiphene monitored with blood tests? (K-07) Was the treatment with clomiphene monitored with ultrasound? (K-08) How severe were the side effects you experienced while taking clomiphene? (Please mark (K-09) Other than clomiphene, have you at any time taken any other medication by mouth to induce ovulation? If yes, what medication(s) did you take? _______________________________________________ (K-10) In order to achieve pregnancy, have you at any time taken any medication by injection to induce ovulation? If yes, what medication(s) did you take? _______________________________________________ (K-11) In order to achieve pregnancy, have you at any time taken progesterone by prescription? (K-12) In order to achieve pregnancy, have you at any time taken any other medications to enhance fertility? If yes, please describe: ______________________________________________________________ (K-13) Have you had artificial insemination? How many cycles with husband’s sperm? __________________ How many cycles with donor sperm? ______________________
L. Previous Assisted Reproductive Technology (ART)

These next questions are about in-vitro fertilization (IVF) or similar ART treatments, such as intra-
cytoplasmic sperm injection (ICSI), gamete intra-fallopian transfer (GIFT), or zygote intra-fallopian transfer
(ZIFT). By ART treatment, we mean any treatment that involves removing the egg from the woman’s body
and then replacing the egg or embryo back into the body.
(L-01) Have you ever been advised by a physician or practitioner to try IVF, ICSI, or any other ART?
(L-02) Have you ever attempted IVF, ICSI or any other ART?
If no, please skip to Section M, Experience of Past Fertility Treatment on the next page; if yes,
continue to question L-03.

(L-03) If yes, please complete the following table for all IVF, ICSI, or any ART attempts, regardless
of outcome:

M. Experience of Past Fertility Treatment
These questions help us understand your previous experiences with evaluation and treatment.
(M-01) Have you or your partner ever been evaluated or treated for fertility problems or miscarriage in the
past, not including NPT (NaPro Technology)?

If no, please skip to Section N, Adoption, page 16; if yes, continue to question M-02.

In the next questions, please consider your overall experience with medical evaluation and treatment for infertility or miscarriage that you and your partner have had in the past (not including NPT). Please answer from your own perspective, not necessarily your partner’s. How do you assess the doctors and the staff that you have worked with? (M-02) Did they make you feel you had enough time during the consultations? (Please mark (M-03) Did they involve you in decisions? (Please mark (M-04) Did they listen to you? (Please mark (M-05) Did they explain the purpose of examinations, tests, and treatments? (Please mark (M-06) Did they tell you what you wanted to know about the causes of infertility and/or miscarriage? (Please mark (M-07) Did they tell you what you wanted to know about the treatment of infertility and/or miscarriage? (Please mark (M-08) Did they deal with emotional consequences of your infertility or miscarriage and treatment? (Please mark (M-09) Did they make a treatment plan adjusted to your special situation? (Please mark
(M-10) What have you liked most about you and your partner’s past treatment?
_________________________________________________________________________________
_________________________________________________________________________________ _________________________________________________________________________________ (M-11) What have you liked least about you and your partner’s past treatment? _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ (M-12) What is your overall satisfaction rating for you and your partner’s past treatment, rated from 1-10? (Please mark
N. Adoption
(N-01) Have you ever applied for adoption?
(N-02) Do you have any adopted children?
(N-03) Have you ever had foster children?

(N-04) Do you currently have any foster children?

P. General Health History

(P-01) Which of the following conditions have you ever had? (Please mark
Non-insulin-dependent diabetes mellitus Cancer (describe): _______________________________________________________________ Hormone problems (describe): ______________________________________________________ Other autoimmune disease (describe): ________________________________________________ Food intolerance (describe): ________________________________________________________ Other medical problems (describe): __________________________________________________ If yes, please describe: ______________________________________________________________ (P-03) Please list all drugs, vitamins, or herbs you are currently taking on a regular basis, whether they are prescribed or over-the-counter: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ (P-04) What has been your lowest weight as an adult? and ______Pounds
(P-05) What has been your highest weight as an adult (not including any pregnancy)? and ______Pounds
and ______Pounds
(P-07) Have you ever experienced unexplained increases in your weight? (P-08) Have you ever experienced unexplained decreases in your weight? (P-09) Has a medical professional ever expressed a concern about your weight? (P-10) Have you ever had an eating disorder (such as anorexia, bulimia, or others)?
(P-11) Have you been immunized against rubella (German measles)?

In general, how much do you experience the following symptoms: (Please mark (P-16) Do you have unwanted/excessive hair growth? (P-18) Do you have dizziness or light headedness before meals? The next 10 questions address potential environmental or occupational exposures. Please indicate whether you have had a significant exposure to each of these. (Please mark (P-19) Ionizing radiation other than medical x-rays (gamma rays, x-rays, alpha and beta particles, neutrons). (P-20) Magnetic radiation from towers (electromagnetic energy radiated or transmitted as rays or waves). (P-21) Chemical solvents (liquid substance capable of dissolving other substances). (P-22) High noise levels (such as jack hammering, rock concerts, headsets with high volume). (P-23) Heavy metals (such as lead, cadmium, or mercury). (P-24) Pesticides (chemicals used to kill insects). (P-25) Herbicides (chemicals used to kill weeds or unwanted plants). (P-26) Water pollution (water contaminated with sewage, chemicals, or fertilizers). (P-27) Air pollution (smog or particular matter).
If yes, please describe: ______________________________________________________________
Q. Family History

The next few questions are about family history that might relate to your fertility.
(Q-01) Do your biologic mother or father or your siblings have a history of infertility, miscarriages, or other
reproductive problems?
If yes or unsure, please describe: ______________________________________________________ (Q-02) Did your biologic mother take hormones (such as DES) when she was pregnant with you? (Q-03) Which of the following conditions has your biologic mother, father, siblings, grandparents, cousins, nieces, or nephews ever had? (Please mark Non-insulin-dependent diabetes mellitus Other autoimmune disease (describe): ________________________________________________ (Q-04) Does your biologic family have genetic conditions that may be passed on? If yes or unsure, please describe: ______________________________________________________ (Q-05) Does your partner’s biologic family have genetic conditions that may be passed on? If yes or unsure, please describe: ___________________________________________________
R. Health Habits
(R-01) On how many of the past 7 days did you exercise or participate in sports activities for at least 20
minutes that made you SWEAT and BREATHE HARD, such as fast walking, jogging, swimming laps, playing
tennis, fast bicycling, heavy yard work or housework, or similar aerobic activities? (Please mark
(R-02) On how many of the past 7 days did you exercise or participate in sports activities for at least 20 minutes but less vigorously than described above? (Please mark (R-03) Have you ever smoked cigarettes?
If no, please skip to question R-05 below; if yes, continue to question R-04.

(R-04) Do you currently smoke cigarettes? If yes, how many cigarettes do you usually smoke per day? _________________ If no, in what month and year did you quit smoking cigarettes? |___│___│___| / |___│___│___│___| (example: Mar / 1985)
Month / Year
(R-05) Have you ever used tobacco in any other form (pipes, cigars, snuff, chewing tobacco, etc.)?
If no, please skip to question R-07 below; if yes, continue to question R-06.

(R-06) Do you currently use tobacco in some form? If no, in what month and year did you quit using tobacco? |___│___│___| / |___│___│___│___| (example: Mar / 1985)
Month / Year

(R-07) On average during the last month, how many cups of coffee did you drink per day?
(Do not count espresso) (Please mark

(R-08) On average during the last month, how many cups of espresso did you drink per day?
(Please mark

(R-09) On average during the last month, how many cans or bottles of caffeinated soda drinks did you drink
per day, including Coca Cola, Pepsi, and others? (Please mark

(R-10) On average, how many units of alcohol do you drink per week? (Please mark
(1 unit = glass (half-pint) of beer, 1 measure of spirits, 1 small glass of wine) (R-11) In the last month, what is the highest number of units of alcohol you had in a 24-hour period?
(Please mark

S. Stress and Social Situation
Please answer the following questions from your own perspective, not necessarily your partner’s. (S-01) With reference to you or your partner’s fertility problems and treatment, do you feel that: [Please (S-02) How have you or your partner’s fertility problems affected your marriage/partnership? [Please (S-03) How much stress has you or your partner’s fertility problems placed on the following? [Please Your relationships with your family-in-law Your relationships to people with children (S-04) Do you get support and understanding from any of the following people in relation to you or your partner’s fertility problems or treatment? [Please mark Who? _______________________________________________________________ (S-05) Do you experience that some people react negatively to you or your partner’s fertility problems or Who?_______________________________________________________________
T. Demographic Information
The following information is helpful for us to understand who is receiving NPT evaluation and treatment. (T-01) How many years of schooling have you had? (Please mark (T-02) What is your race and ethnicity? (Please mark Other, please specify: _______________________________ (T-03) What is your religious preference? (Please mark Other, please specify: ____________________________ (T-04) About how often do you usually attend religious or worship services? (Please mark (T-05) What is your current occupation? (Please mark Other, please specify: ________________________________ (T-06) What is your approximate yearly total household income? (Please mark

U. Additional Comments or Questions

Please write any additional comments or questions you have about the issues addressed by this
questionnaire:
____________________________________________________________________________________
____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

Source: http://inhisimagefamilymedicine.com/forms/inest_woman_q.pdf

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