Guidelines for scheduling preconception appointments for Dr. Bathgate:

• Please urge new patients to come early to fill out paper work and verify insurance.
• The patient’s partner is invited and encouraged to come to the appointment.
• The woman and her partner should both fill out the preconception questionnaires and bring these completed questionnaires with them to their appointment.
• If they have any specific medical questions about past conditions, if possible please have them bring copies of any medical records or tests that they might have.
• A physical exam is not part of the preconception visit. If they are in need of an annual exam or have a specific physical problem requiring an examination, they should schedule a separate visit for this.
• Please mail or fax a set of one female and one male preconception questionnares to the patient at the time she makes the appointment.
• Encourage the couple to notify our office in advance of her appointment if she has not received the questionnaires.

Thank you.

Dear Patient,

Thank you for scheduling an appointment with me for preconception counseling. My interest in helping couples prepare for pregnancy comes from my work with complicated and high risk pregnancies. My goal is to identify and help modify risk factors for poor prenancy outcome before pregnancy whenever possible.

To make the most out of your appointment, I would like you and your partner to complete the enclosed questionnaires before your appointment, and bring them with you to your visit. If you have particular medical questions about past or current medical conditions, please bring any copies of medical records and results of tests that you may have. I look forward to seeing you at your upcoming appointment.

Sincerely,

Susanne L. Bathgate, MD

Assistant Professor

Division of Maternal-Fetal Medicine

INTRODUCTION

The Pre-Conception Program of the Department of Obstetrics & Gynecology and the Center for Integrative Medicine at George Washington University Medical Center is a clinical program designed to optimize your obstetrical potential. We believe that by putting you in an optimal health – physical, emotional and social – environment, you will achieve the best possible obstetrical outcome. This may mean the reduction or prevention of miscarriages and other pregnancy related complications. If you have difficulty in conceiving, the program may enhance the results of your fertility treatments.

This program is based on the sound principle of prevention and supported by the result of the Foresight Program of the University of Surrey, England (web address), which was established in 1990. This is a six month program starting with two months of testing, diagnosis and planning followed by four months of implementation of the treatment plan, prior to any effort to conceive. It is rigorous and demands your and your partner’s commitment and active participation in every phase of the program. We will provide tools, guidance and encouragement and you have to do the work.

The first step is to fill out the enclosed questionnaire. This is your complete health inventory and forms the basis of our management plan. It is therefore important that you fill this out to the best of your ability. We will address any questions and concerns at the initial interview. This is part of your confidential medical record and will not be shared with anyone other than direct caregivers without your expressed permission.

We are privileged to be your healthcare partners and we are committed to do our best to help you reach your healthcare goals.

Susanne Bathgate MD John Pan MD

Assistant Professor Clinical Professor

Medical Director – Pre-Conception Program Director

Department of Obstetrics & Gynecology Center for Integrative Medicine

PATIENT INFORMATION

Name __________________________________________

Spouse/Partner’s Name_____________________________

Address _________________________________________

______________________________ zip______________

Tel: Home ________________Work___________________

Fax______________________E-Mail__________________

Date of Birth ___________________________Age_______

Education ________________________________________

Occupation _______________________________________ 

Were you referred by another healthcare professional? If so, by whom were you referred?

What do you hope to achieve by participating in this preconception program?

What are your goals?

PATIENT INFORMATION

Name __________________________________________

Spouse/Partner’s Name_____________________________

Address _________________________________________

______________________________ zip______________

Tel: Home ________________Work___________________

Fax______________________E-Mail__________________

Date of Birth ___________________________Age_______

Education _______________________________________

Occupation _______________________________________ 

Were you referred by another healthcare professional? If so, by whom were you referred?

What do you hope to achieve by participating in this preconception program?

What are your goals?

MEDICAL HISTORY 

Past Medical Illnesses: (Check diseases/conditions that apply to you. Indicate date if in the past.)

Please use the bottom or reverse side of the page to elaborate if necessary.

Review of Symptoms: (Check symptoms that apply to you)

Last dental examination ______________

Have you ever been vaccinated against:

Have you been diagnosed and/or treated for cancer?

What kind ______________________________________________When:________________

What type of treatment & dates: __________________________________________________

___________________________________________________________________________

Have you been diagnosed and/or treated for a psychiatric disorder or sought counseling?

What type:_____________________________________________________________________

Describe treatment & dates:________________________________________________________

Have you been hospitalized for any illness? Please describe:

______________________________________________________________________________

______________________________________________________________________________

Have you ever had injuries (broken bones, concussion, etc.) or accidents? Please describe & date

_____________________________________________________________________________

_____________________________________________________________________________

Have you had any surgery? Please describe & date

______________________________________________________________________________

_____________________________________________________________________________

Have you had a blood or plasma transfusion?______________

Allergies (drugs, food, etc.)

______________________________________________________________________________

FAMILY & GENETIC HISTORY  

MEDICAL

Any of your blood relatives have :

Stroke ___ who ________ Heart Disease ___ who ________

High Blood Pressure ___ who ________ Diabetes___ who ________

Blood Clots/Phlebitis ___ who ________ Arthritis ___ who ________

Tuberculosis ___ who ________ Alcoholism ___ who ________

Cancer ___ Type ____________________________ who____________________________

Psychiatric Disorder ___ Type ___________________ who __________________________

Other medical problems __________________________________________________________

GENETIC

Do you have any children with birth defects, handicaps, or a genetic disease? ___

Explain _______________________________________________________________________

Are you and your partner blood relatives? _____ Explain ________________________________

Any of your blood relatives have the following: (check)

Ethnicity:

What is your ethnic background?

What countries or parts of the world are your ancestors from?

Do you have any of the following in your ancestry:

Have you been tested for any of the following? If so, indicate carrier (c) or non-carrier (n)

Residence & Travel

Country of birth _______________ Have you lived outside the US ___________

Where & When _____________________________________________________

Do you or your partner regularly travel outside US ______

Where & How Often _________________________________________________

Domestic

Who lives in your household:______________________________________________

Are you a caretaker outside your home? Who _________________________________

Do you have smoke detectors ____ Do you have cats in your household _____

Occupation

What is it? _____________________________

Describe your typical work day:_____________________________________________

Do you commute: _______ How long: ________ Use seat belt? ______

Toxic Exposures – Are you regularly exposed to, in contact with or consume:

Domestic Violence

*You may choose to answer the following questions personally if you prefer

In the past 12 months :

Has anyone threatened you with or actually used a knife or gun to scare or hurt you? ___

Has anyone choked, kicked, bit or punched you? ___

Has anyone slapped, pushed, grabbed or shoved you? ___

Has anyone forced or coerced you to have sex? ___

Have you been afraid that a current or former intimate partner would hurt you physically?

If any of the above answer is yes:

What is the relationship with the person who hurt you? __________________________

Have the police been notified? ______ When: __________________________________

NUTRITION, WELLNESS & LIFESTYLE 

Height____ Weight: Now_____ One year ago_____ Maximum _____ When?_________________

Describe weight fluctuation _________________________________________________

I consider my weight to be: (Please check which statement applies to you)

____not a factor in my present health issues

____somewhat a factor

____a significant factor

Do you smoke?____ If so, how many packs per day?____

Are you exposed to second hand smoke?__________

Do you drink alcohol?____ How many drinks per week?____

Do you drink caffeinated coffee?____ How much?____

Have you ever used intravenous drugs?____

Please describe your present eating style (Please check any that apply)

Omnivore (Include meat/poultry/fish/eggs/dairy)____

Semi-vegetarian____ (I exclude some animal products, specifically______________________________).

Ovo-lactovegetarian (I exclude all animal flesh but include dairy and eggs)____

Vegan (I do not include any animal products)____

Macrobiotic____

Other (Please describe)_________________________________________________________________

How many times per week do you eat red meat?____

How many times per week do you eat chicken or fish?____

How many times per week do you eat desserts?____

Indicate how many servings of fruits and vegetables you eat per day____

How many whole eggs do you eat a week?____

How often do you eat out?____

Do you eat unpasteurized cheese or unpackaged deli meat or cheeses _______

Do you regularly add salt at the table?____

I have food allergies and/or intolerances (please describe)______________________________________

I tend to eat pretty much the same things on a regular basis, i.e., not a lot of variety____

I tend to skip meals, specifically___________________________________________________________

I tend to snack a lot, specifically throughout the day____; mainly at night____

I tend to overeat if I am not careful_____

I often succumb to food cravings, specifically_________________________________________________

I am concerned about getting optimum nutrition because of______________________________________

Briefly, how would you describe your diet (what ever you want to say)____________________________

_________________________________________________________________________________

__________________________________________________________________________________

Recent improvements that I have made in my diet include_______________________________________

___________________________________________________________________________________

The factors in my life that interfere with eating better are_________________________________________

____________________________________________________________________

My interest and motivation to make and sustain improvements in my diet at this time are:

____none ____slight ____moderate ____strong ____very strong

Do you participate in aerobic exercise?____ How often?____

How many minutes do you exercise at one time?____

Do you perform strength training or floor exercises, resistance training or lift weights?____

Do you stretch regularly?____

Describe any physical problems that prevent you from exercising ______________________________

Have you felt tired, worn out, or exhausted during the past month?____

How often do you get at least 7 to 8 hours of sleep each day?_____

Do you often have insomnia?____

Do you consider yourself generally happy these days? ______

Do you feel as though you have a strong social support system/people to talk to, share things with (family, friends)?____

How many sick days have you taken in the past 12 months due to sickness or injury?____

Do you feel as though you are often under stress or pressure?____

On a scale from 0 to 10, where 0 is a thoroughly easy-going person and 10 is a very high-strung person, please rate how you generally consider yourself. ____ How do you think others would rate you?____

Please identify the three biggest stresses in your life right now

1.

2

3.

If there were three things you could change about yourself right now, what would they be?

1.

2.

3.

Please describe two or three of your greatest strengths and/or achievements

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

Are you generally satisfied with your job?____

Please describe any physical factors or environmental problems at work that impact your health, safety or job satisfaction (for example: temperature, workspace, relations with coworkers, etc.) ________________________________________________________________________

________________________________________________________________________

How important is spirituality in your daily life? (Not important) 1 2 3 4 5 (Very Important)

Do you participate in a faith community?____

What is your religious affiliation?_____________________________

How important is your religious affiliation in your daily life? (Not important) 1 2 3 4 5 (Very important)

Have you ever fathered a pregnancy before?________

If so, was the pregnancy miscarried or aborted?__________

Do you have any children?________

What is the health of the child or children?_______________________________

Have you ever had sores or rashes of the penis?

Have you previously been treated for a sexually transmitted disease?________________

Have you ever had any genital injuries or surgeries?_______________________

Have you ever sought evaluation or treatment for difficulty conceiving?___________

If so, what tests or treatments have you had, and what were the result?__________

__________________________________________________________________

__________________________________________________________________

OBSTETRIC, GYNECOLOGIC & FERTLITY HISTORY

Date of last gynecologic exam __________Pap smear result ______ Previous abnormal____

Date of last mammogram______________

Current method of birth control: Pills ___ Injections ___

Condom/Diaph ___ IUD ___Rhythm ___ None ___

Past method of birth control: Pills ___ Injections ___

Condom/Diaph ___ IUD ___Rhythm ___ None ___

Previous Gynecologic Surgery (list date, type, indication):

Do you have history of:

Painful intercourse ____ Sexual dysfunction _____________________________

Genital Herpes ____Genital Warts ____STD ______Recurrent vaginal infections ____

Partner with penile discharge or sores ____

Uterine Fibroids_____ Endometriosis ______ Infertility______

Ovarian cysts_____ Fibrocystic Breasts______

Have you ever been tested for chlamydia or gonorrhea ________

H ave you been tested for chlamydia or gonorrhea during this relationship__________

Menstrual History

Date of last menstrual period: _____________ Age of onset: ______

Length of menstruation _________days Frequency, every __________days

Amount: ___ Heavy ___Medium ____Light

Cramps: ___Severe ___Moderate ____Mild

Abnormal Period ____ Describe:

Medications (including herbs):

_________________________________________________________________________________

Pregnancy History

Infertility History

Primary infertility ___ How long ____ Secondary infertility ___ How long ____

Male factor ___ What kind _______________________________________________

Work-up: Hormonal/BBT ___ HSG ___ Laparoscopy ___

Result: ___________________________________________________________________________

Treatment: Ovulation induction ___ Corrective surgery ___ IVF ___

Describe:__________________________________________________________________________

Medications (including herbs):

_________________________________________________________________________________

COMPLEMENTARY ALTERNATIVE MEDICAL CARE HISTORY  

Please check each type of complementary care that you have tried or that interests you:

TRIED INTERESTED TRIED INTERESTED

Others: ___________________________________________________________________________

If you have already tried a complementary therapy, please explain the reason you selected the therapy

and your goals. How effective has the therapy been? ______________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Please list the practitioners: ___________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

Do you use herbs or vitamin supplements? What are you using? For what purpose?_______________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

_________________________________________________________________________

Medication History  

What prescription medications are you now taking or have you taken in the past?

What nonprescription (over-the-counter) medications are you now taking or have you taken in the past?

October 2002