General Practitioner Template
Female infertility
A professional General Practitioner template for healthcare professionals.
About this template
This female infertility template is designed for General Practitioners to document comprehensive patient histories related to infertility issues. It covers key areas such as pregnancy history, menstrual cycle irregularities, and potential complications like endometriosis or PCOS. The template also includes sections for past medical and surgical history, family history, and lifestyle factors, providing a holistic view of the patient's health. This template is ideal for clinicians seeking to streamline the documentation process and ensure all relevant information is captured efficiently. Use this template to enhance patient care and improve diagnostic accuracy.
Preview template
FEMALE:
Presenting Issue:
- The patient presents with concerns about infertility, reporting difficulty conceiving for the past two years despite regular unprotected intercourse. She experiences irregular menstrual cycles and occasional pelvic pain.
Pregnancy Hx:
- The patient has a history of one miscarriage at 8 weeks gestation, no live births, and no abortions.
Parity:
- 1 pregnancy, 0 live births, 1 miscarriage.
TTC:
- The patient has been trying to conceive for 2 years. She has undergone ovulation induction therapy without success.
Complications:
- No complications reported during the previous pregnancy.
Types of delivery:
- Not applicable as there have been no deliveries.
PMHx:
- The patient has a history of hypothyroidism, currently managed with medication.
Menstrual cycle:
- The patient reports irregular menstrual cycles, ranging from 30 to 45 days.
Bleeding:
- Occasional heavy bleeding lasting up to 7 days.
Dyspareunia:
- The patient reports mild dyspareunia, particularly during deep penetration.
Dyschezia:
- No painful bowel movements reported.
Dysuria:
- No painful urination reported.
Premenstrual spotting:
- The patient experiences spotting 2-3 days before menstruation.
Endometriosis:
- Endometriosis is suspected due to pelvic pain and irregular cycles.
CST:
- The most recent cervical screening test was normal, conducted in January 2023.
Anorexia:
- No anorexia reported.
Hypothalamic amenorrhoea:
- Not suspected.
PCOS:
- Polycystic ovary syndrome is suspected based on irregular cycles and ultrasound findings.
Hyper/Hypo-androgenism:
- No signs of androgen imbalance reported.
Urological Hx:
- No significant urological history.
Other conditions:
- None reported.
PSHx:
- Appendectomy in 2015.
Allergies:
- Allergic to penicillin, causing rash.
Medicines:
- Levothyroxine 50 mcg daily.
FMHx:
Maternal:
- Mother has a history of type 2 diabetes.
Paternal:
- Father has a history of hypertension.
SHx:
EtOH:
- Consumes alcohol socially, approximately 2-3 drinks per week.
Smoking:
- Non-smoker.
Rec drug use:
- Denies any recreational drug use.
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