Download QUESTIONNAIRE REGARDING REPRODUCTIVE SYSTEM

Arnold Vera, M.D., M.Sc., F.A.C.E., C.D.E.
Vera Endo Wellness Institute
Melanie Shiffman, B.A.
The Spectrum of Volusia County
QUESTIONNAIRE REGARDING
REPRODUCTIVE SYSTEM
Today, the art and science of Medicine, along with the daily care of the patient, allows us to
learn that the human being, besides their physical pain, many of them suffer “pain in their
soul,” which cause, nature and genesis resides in the “deep and recondite origin of their
life,” although perhaps beginning before conception. After all, matter takes place in shape
and meaning based on individual genetic endowment (subatomic particles, atoms,
molecules, genes). Then, the environment modulates in a different fashion: this phenotype
(physical) either at molecular, cellular, tissue, organ, system levels or whole body.
Therefore, we must medically act to diagnose and treat the person and not the disease.
Arnold Vera
© Copyright 2011 Arnold Vera, M.D., M.Sc., F.A.C.E., C.D.E.
Page | 1
Arnold Vera, M.D., M.Sc., F.A.C.E., C.D.E.
Vera Endo Wellness Institute
Melanie Shiffman, B.A.
The Spectrum of Volusia County
QUESTIONNAIRE REGARDING REPRODUCTIVE SYSTEM
(Please answer to the best of your knowledge)
Age/years________ DOB: ___/__/____
Weight: ______________________ Height: ___________
Smoking: ____
NON-Smoking: _________
1. Ethnicity / Race: (Mostly 75% or more)
1.1 African -American:
Yes____
1.2 Arabic-American:
Yes____
1.3 Asian-American:
Yes____
1.4 Caucasian (European, Scandinavian, etc.):
Yes____
2.
3.
4.
1.5 Hindu-American:
1.6 Hispanic-American:
1.7 Native American:
1.8 Persian American
1.9 Other American:
Yes____
Yes____
Yes____
Yes ___
Yes____
Age of your first menstrual period (MP) _______years of age
Is your MP normal/regular every month? Yes____ No____
How many times do you menstruate per year? _____
5. Last MP: __/__/____
Currently post-menopausal? Yes _____
6. Has your menstrual period been absent for 3 months or more without being
pregnant)? Yes____ No____
Does the absence of menstrual period or menstrual period irregular has been accompanied by excess of
6.1 Body hair yes ____ no _____
If yes, where:
Mustache _____
Upper Arm _____
Sideburn ______
Thighs ______
Chest/around breast ___
Back ______
Abdomen _____
Legs _____
6.2 Losing hair on your head (baldness, alopecia) Yes ____ No ____
If yes, Mild _____ Moderate _____ Severe _____
6.3 Acne or Pimples yes _____ No _____
If yes, Mild _____ Moderate _____ Severe _____
7.
Pregnancies and Deliveries
Pregnancies: Spontaneous (# and years) __________ Artificially Induced (# and years) ________
Deliveries: Natural _____ Caesarean Section 1 st ____ 2nd ____ 3rd ____ 4th or more ____
Miscarriages: one ___ two ___ three ___ four ___ five or more ___
Abortion: Yes _____ No _____
Ectopic Pregnancies: Yes ____ No _____
8. Have you ever used birth control pills, contraceptive patch, vaginal ring, injections, or any other hormonal
method of contraception? Yes____ No____
If yes, for how long:
8.1 Starting age of birth control: ______
8.2 Less than 6 months ____ 8.3 less than 1 year ____
8.4 1-2 years____
8.5 3-4 years ____
8.6 5-7 years____
8.7 8-10 years____
8.8 11-13 years____
8.9 14 years or more____
© Copyright 2011 Arnold Vera, M.D., M.Sc., F.A.C.E., C.D.E.
Page | 2
Arnold Vera, M.D., M.Sc., F.A.C.E., C.D.E.
Vera Endo Wellness Institute
Melanie Shiffman, B.A.
The Spectrum of Volusia County
9. How long did you stop birth control pill before you got pregnant?:
9.1 Did you conceive immediately after you stopped your birth control pill (you did not see
your menstrual period before conception after you stopped your birth control pill)? Yes____ No____
9.2 Did you stop for 3 months or less?____ 9.3 Did you stop for 4 - 6 months?____
9.4 Did you stop for 7-9 months?____
9.5 Did you stop for 10-12 months?____
9.6 Did you stop for more than 1 year, but less than 2 years?____
9.7 Did you stop for more than 2 years, but less than 4 years ____
9.8 Did you stop for more than 4 years: ____
9.9 If more than 1 pregnancy after stopping birth control pill, please specify
_______________________________________________________________________________________
_______________________________________________________________________
10. Was the pregnancy after the birth control pill spontaneous (natural) yes ____ no ____
or artificially induced? Yes _____
11. If the pregnancy was “artificially induced”, was it with
11.1 drugs, pills, tablets_____
11.2 injection _______ 11.3 insemination _____
11.4 in vitro fertilization _____
11.5 others _____
12. If more than 1 pregnancy was “artificially induced” (see above) and carried until term, please
specify if appropriate___________________________________________________
____________________________________________________________________
13. Have the child/children being a result of the above pregnancy/pregnancies after birth control pill or any hormonal
contraceptive method been diagnosed with any of the following:
13.1 Growth disorders:_______________________ Yes____ No ____
13.2 Developmental Delay ___________________ Yes____ No____
13.3 Neuropsychological disorders: ____________ Yes ____ No ____
13.4 Autism Spectrum Disorder_______________ Yes ____ No ____
(Autism of any type)
13.5 Attention deficit disorder (any type): ________ Yes ____ No ____
13.6 Language and/or hearing disorders: ________ Yes ____ No ____
14. Have the child/children being a result of any artificially induced pregnancy been diagnosed with any of the following:
14.1 Growth disorders:_______________________ Yes____ No ____
14.2 Developmental Delay ___________________ Yes____ No____
14.3 Neuropsychological disorders: ____________ Yes ____ No ____
14.4 Autism Spectrum Disorder_______________ Yes ____ No ____
(Autism of any type)
14.5 Attention deficit disorder (any type): ________ Yes ____ No ____
14.6 Language and/or hearing disorders: ________ Yes ____ No ____
15. Please check if you never take or took birth control pills or apply any hormonal method of contraception _____
16. Have the child/children being a result of any spontaneous (no induced or artificial pregnancy been diagnosed with any
of the following:
16.1 Growth disorders:_______________________ Yes____ No ____
16.2 Developmental Delay___________________ Yes____ No____
16.3 Neuropsychological disorders: _ Yes ____ No ____
16.4 Autism Spectrum Disorder_______________ Yes ____ No ____
(Autism of any type)
16.5 Attention deficit disorder (any type): ________ Yes ____ No ____
16.6 Language and/or hearing disorders: ________ Yes ____ No ____
17. Have you been diagnosed and/or treated for Postpartum Depression:
Yes ____ No ____
>>>> OVER >>>>
© Copyright 2011 Arnold Vera, M.D., M.Sc., F.A.C.E., C.D.E.
Page | 3
Arnold Vera, M.D., M.Sc., F.A.C.E., C.D.E.
Vera Endo Wellness Institute
Melanie Shiffman, B.A.
The Spectrum of Volusia County
18. Have you or your family (husband/father of your child) or his family or children been diagnosed
with (answer if appropriate and accordingly):
You
Your
Family
Member
Husband/father
of your child
His Family
Member
Type 1 Diabetes Mellitus
Adrenal Gland Disorders (Addison’s
disease)
Alopecia/Baldness
Ankylosing Spondilitis
Ascending Cholangitis
Autoimmune Hepatitis
Celiac Disease/Gluten Intolerance
Connective Tissue Disease
Crohn’s Disease
Dermatomyositis
Early Grey Hair
Early Menopause (meaning before 35
years-of-age)
Endometriosis
Fibromyalgia
Hypoparathyroidism
Interstitial Lung Disease
Lupus / or Lupus Anticoagulants or
Lupus Antiphospholipid
Multiple Sclerosis
Myasthenia Gravis
Pernicious Anemia
Polyarteritis Nodosa
Polymyalgia rheumatica
Primary Biliary Cirrhosis
Psoriasis
Pulmonary Fibrosis
Rheumatoid Arthritis
Relaxing Polichondritis
Sarcoidosis
Sjogren’s Syndrome
Scleroderoma
Systemic Sclerosis
Thrombocytopenia (low platelets)
Thymoma / Thymus Tumor
Thyroid Gland Disorders:
Goiter, Nodules.
Graves’ Disease/ Hyperthyroidism.
Hashimoto’s/Hypothyroidism.
Ulcerative Colitis
Vasculitis
Vitiligo
Other Autoimmune Disease / Disorder

Thank you very much for taking the time to complete this Questionnaire!
© Copyright 2011 Arnold Vera, M.D., M.Sc., F.A.C.E., C.D.E.
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Your Child/
Children