This form was designed for a lupus patient to complete if she is considering pregnancy in the future. She should print and complete this form, then take it with her for pre-pregnancy discussion with her attending physician or gynecologist.

Reproductive History

1. What concerns do you have about pregnancy? _________________________________________________
   
   _______________________________________________________________________________________
   
   _______________________________________________________________________________________
   
   
2. At what age did you have your first menstrual period?  _____
   
   
3. What was the date of your last menstrual period?  __________
   
   
4. Are your menstrual periods regular?      YES       NO
   
   
5. How many days between menstrual periods?  _____
   
   
6. How many days do your menstrual period usually last?  _____
   
   
7. Do you have pain with your menstrual periods?     YES      NO
   
   
8. Describe any problems that you have with your periods, currently or in the past:  _________________________________________________
   
   _______________________________________________________________________________________
   
   _______________________________________________________________________________________
   
   
9. How many children would you like to eventually have?  _____
   
   
10. Have you had surgery, especially on your female organs (gynecological surgery)?      YES     NO       If yes, please describe:
    When:  _________________________________________________
    
    Procedure performed: 
    _______________________________________________________________________________________
    
    _______________________________________________________________________________________
    
    Findings or recommendations: 
    _______________________________________________________________________________________
    
    _______________________________________________________________________________________
    
    
11. Have you discussed pregnancy with you physician?      YES       NO      If yes, what was the result of the discussion?
    _______________________________________________________________________________________
    
    _______________________________________________________________________________________
    
    
12. What method of birth control are you currently using?
    _______________________________________________________________________________________
    
    
13. Have you ever tried to become pregnant and not succeeded?     YES     NO
    
    
14. If you have been pregnant in the past, how many pregnancies have you had? _____
    
    Spontaneous miscarriages (up to 12 weeks):  _____
    
    Medical termination of pregnancy:  _____
    
    Miscarriages (after 12 weeks):  _____
    
    Fetal death (after 12 weeks):  _____
    
    Stillbirths (greater than 24 weeks):  _____
    
    Completed pregnancies – living children:  _____
    
    Additional Comments: 
    _______________________________________________________________________________________
    
    _______________________________________________________________________________________
    
    

Medical History

1. List medications you are currently taking:
   _______________________________________________________________________________________
   
   _______________________________________________________________________________________
   
   
2. Any allergic reactions to any medications?       YES     NO
   
   Be specific: 
   _______________________________________________________________________________________
   
   _______________________________________________________________________________________
   
   
3. Please list any other significant medical history:
   _______________________________________________________________________________________
   
   _______________________________________________________________________________________
   
   _______________________________________________________________________________________
   
   _______________________________________________________________________________________
   
   

Lupus History

1. When were you first diagnosed with Lupus Erythematosus?  __________
   
   
2. What has been your most serious complications? 
   
   _______________________________________________________________________________________
   
   _______________________________________________________________________________________
   
   
3. How long have you been followed by this physician?  __________
   
   
4. When was your last appointment with your physician?  __________
   
   
5. Are you currently experiencing any problems with lupus?     YES     NO     If yes, please describe:
   
   _______________________________________________________________________________________
   
   _______________________________________________________________________________________
   
   
6. Do you have a history of high blood pressure?      YES     NO   If yes, list blood pressure medications you are currently taking:
   
   _______________________________________________________________________________________
   
   _______________________________________________________________________________________
   
   
7. Have you ever been told you have kidney involvement due to your lupus condition?     YES     NO   If yes, please describe:
   
   _______________________________________________________________________________________
   
   _______________________________________________________________________________________
   
   
8. Do you have a history of thrombophlebitis, blood clots, seizures or strokes?     YES     NO   If yes, please describe:
   
   _______________________________________________________________________________________
   
   _______________________________________________________________________________________
   
   
9. Have you ever been told that you have antiphospholipid antibody syndrome?     YES     NO
   
   
10. Have you ever been told you have a low platelet count?     YES     NO