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Reproductive and Blood Clotting History Questionnaire
Thank you for taking the time to consider the questions below. For some of you, we know that these
questions may be emotionally difficult to answer and we sympathize. Your participation in this study is important and much appreciated. Please be sure to
mail your questionnaire promptly upon completion. If you have questions regarding this form, please do not hesitate to contact us at the above location.
You can also reach us by fax (513-585-7950) or by email (glueckch@healthall.com). If you are uncertain about your obstetrical or medical history, your
obstetrician or otherwise your family physician will likely be happy to answer your questions.
Name: (Last, First)__________________________________________ Date________
Address______________________________________________________________
Phone:_____________________________ e-mail address______________________
Have you had any pregnancy Without Any fertility assisting drugs or procedures? y / n
Have you had any pregnancy on Metformin treatment? y / n
Have you had any pregnancy on any other fertility assisting drugs and/or procedures? y / n
I. About the pregnancies Without Any fertility assisting drugs or procedures:
1. Number of pregnancies________
2. Number of full term (37 weeks or more) live births_______
3. Number of premature (less than 37 weeks) live births_______
a. Number of live births before 36 weeks ________
b. Number of live births before 28 weeks ________
c. Number of live births from 28-31 weeks________
d. Number of live births from 32-35 weeks________
4. Number of miscarriages (death and delivery of the fetus) prior to 13 weeks _______
5. Number of miscarriages after 13 week _______
6. Number of stillbirths (infant born showing no signs of life) _______
7. Number of:
a. newborns delivered before 37 completed weeks gestation who are appropriate size for gestational age, AGA preterm
neonates_________
b. newborns delivered before 37 completed weeks gestation who are small for gestational age, SGA preterm and
growth-restricted neonates__________
c. newborns delivered after 37 completed weeks gestation who are small for gestational age, SGA restricted
neonates_________
Note: For the following 1 pound equals 454 grams
d. live births weighing less than 2500 grams _________
e. live births weighing less than 1500 grams _________
f. live births weighing less than 1000 grams _________
g. live births weighing more than 500 but less than 1000 grams _________
8. Number of physician assisted terminations (not represented in the above categories) _____
9. Number of pregnancies complicated/associated with eclampsia (high blood pressure) ______
If your answer to #9 was not zero, were you given medicine to lower your pressure? ______
10. Number of pregnancies complicated by abruption (premature placental detachment) ____
If your answer to #10 was not zero, at what week of pregnancy did this occur? _______
II. About the pregnancies On Metformin treatment:
1. Were you taking Metformin before conception? y / n
If yes, what was the dose _______,
and for how long did you take it _______(months) .
2. After conception was proven, did you continue to take Metformin? y / n
If yes, for how long during the pregnancy ? _______(months)
3. What was the outcome of the pregnancies on Metformin treatment ?
a. Full term (37 weeks or more) live births _______
b. Premature (less than 37 weeks) live births _______
c. Number of live births before 36 weeks ________
d. Number of live births before 28 weeks ________
e. Number of live births from 28-31 weeks _______
f. Number of live births from 32-35 weeks _______
g. Miscarriage (death and delivery of the fetus) prior to 13 weeks _______
h. Miscarriage after 13 weeks _______
i. Stillbirth (infant born showing no signs of life) _________
j. Number of:
1. newborns delivered before 37 completed weeks gestation who are appropriate size for gestational age, AGA
preterm neonates ________
2. newborns delivered before 37 completed weeks gestation who are small for gestational age, SGA preterm and
growth-restricted neonates ________
3. newborns delivered after 37 completed weeks gestation who are small for gestational age, SGA restricted
neonates __________
4. live births weighing less than 2500 grams _________
5. live births weighing less than 1500 grams _________
6. live births weighing less than 1000 grams _________
7. live births weighing more than 500 but less than 1000 grams ________
k. Physician assisted terminations (not represented in the above categories) _______
l. Pre-eclampsia ( ) or eclampsia ( ) (high blood pressure) _______
m. Were you given medicine to lower your pressure? y / n
n. Abruption (premature placental detachment ) _______
o. If you had abruption, when did this occur? (week) _______
III. About other Fertility treatment programs you participated:
1. What fertility-enhancing drugs have you taken _________________________________,
for how long (for each treatment regimen) ________________________________(months).
2. With each fertility-enhancing drug program, what was the outcome (for each treatment regimen)
_______________________________________________________
3. Have you participated in in-vitro fertilization programs y / n
If yes, please describe the program and the outcome ____________________________________________________
IV. If you have never been pregnant:
1. Did you ever try to become pregnant? y / n
2. Do you have a medical condition which prevents you from becoming pregnant? y / n
If your answer to #2 was yes, what is your diagnosis? ________________________________
V. If you have ever had blood clots in the leg veins (phlebitis):
1. Number of times (total) _______
2. Number which occurred while pregnant _______
3. Number which occurred while taking birth control pills or replacement estrogen _______
VI. If you have ever had a blood clot in your lungs (pulmonary embolus):
1. Number of times (total) _______
2. Number which occurred while pregnant _______
3. Number which occurred while taking birth control pills or replacement estrogen _______
VII. If you have ever had a section of bone die (osteonecrosis or avascular necrosis):
1. Number of times (total) _______
2. Number which occurred while pregnant _______
3. Number which occurred while taking birth control pills or replacement estrogen _______
4. In what location of your skeleton did they occur (i.e. hip, jaw, shoulder, etc.)?
____________________________________________________________
VIII. If you have had blood clots in the veins of your eyes:
1. Number of times (total) _______
2. Number which occurred while pregnant _______
3. Number which occurred while on birth control pills or estrogen _______
This is the end of the questionnaire, thanks for your time and for returning the completed form
promptly.
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