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PERSONAL INFORMATION:
Note: Fields marked
*
are compulsory
Date
6th September 2010
Name of Wife
*
Name of Husband
*
Email Address
*
Please ensure that this is a valid email address. We only reply by Mail.
Address
characters left.
City of Residence
Country
Select Country
Algeria
Albania
Angola
Argentina
Australia
Austria
Bahamas
Bahrain
Bangladesh
Barbados
Belgium
Belize
Bermuda
Bolivia
Botswana
Brazil
Bulgaria
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Congo
Costarica
Croatia
Curacao
Cyprus
Czech Republic
Denmark
Dominica
Dominican Republic
Ecuador
Egypt
Elsalvador
Equatorial Guinea
Estonia
Ethiopia
Fiji
Finland
France
Germany
Greece
Greenland
Grenada
Guam
Guinea
Haiti
Honduras
Hongkong
Hungary
Iceland
India
Indonesia
Iran
Ireland
Israel
Italy
Ivory coast
Jamaica
Japan
Jordan
Kenya
Kuwait
Latvia
Lichtenstein
Lithuania
Luxembourg
Macau
Madagascar
Malaysia
Maldives
Mali
Malta
Mauritius
Mexico
Monaco
Morocco
Mozambique
Nambia
Nepal
Netherlands Antilles
Netherlands
New caledonia
New Zealand
Nicaragua
Niger
Nigeria
Northern Ireland
Norway
Oman
Pakistan
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto rico
Qatar
Romania
Russia
Rwanda
Saba
Saudi Arabia
Scotland (U.K.)
Senegal
Seychelles
Sierraleone
Singapore
Slovakia
Slovenia
Somalia
South Africa
South Korea
Spain
Sri Lanka
St.Croix
St. John
St. Lucia
St. Martin/St. Marten
St. Thomas
St. Vincent
Sudan
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tanzania
Thailand
Togo
Trinidad & Tobago
Tunisia
Turkey
U.S. Virgin Islands
Uganda
Ukraine
United Arab Emirates
United States America
United Kingdom
Uruguay
Uzbekistan
Vatican City
Venezuela
Wales (U.K.)
Yemen Arab Republic
Zaire
Zambia
Zimbabwe
Pincode
Telephone Number (Residence)
Mobile Number
Married since
Years
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Months
0
1
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11
12
How long have you been trying to get pregnant?
Years
0
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Months
0
1
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How long have you been trying to get
pregnant with doctor's consultation?
Years
0
1
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3
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Months
0
1
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Doctor can be categorised as
Select
General Gynecologist
Infertility Specialist
Reason for Infertility (Why do you think you are not getting pregnant?)
Select Reason
Male Factor Infertility
Tubal Factor
Azoospermia
Low Sperm Count
Endometriosis
Poor Ovarian Reserve
PCOD(Polycystic Ovarian Disease)
Unexplained
Don't Know
Note:
Press control key to select more than 1 options
FEMALE HISTORY:
Age
Birth Date
Height (ft.)
Weight (kg.)
Menstrual periods occur every
Days
Are they regular?
Yes
No
For how many days do you bleed?
Select
1
2
3
4
5
6
7
8
9
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27
29
30
31
Days
Have you been told you have endometriosis?
Yes
No
How was the diagnosis made?
characters left.
When?
Have you ever had pelvic inflammatory disease (PID)?
Yes
No
How was the diagnosis made?
characters left.
When?
Have you ever had pelvic surgery?
Yes
No
Name of Surgery
Year
Year
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
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1991
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1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Findings
Add More Entries
No of Pregnancies with this partner
Select
0
1
2
3
4
No of Pregnancies with previous partner
Select
0
1
2
3
4
Have you ever had a miscarriage?(abortions)
Yes
No
No of Miscarriages
Select
0
1
2
3
4
5
Did you have any tubal (ectopic) pregnancies?
Yes
No
No of pregnancies
Select
0
1
2
3
4
5
Are there any live births?
Yes
No
No of live births
Select
0
1
2
3
4
5
Medical problems and current medications of female partner
Previous
MALE HISTORY:
Age
Birth Date
Are there any pregnancies with previous partner?
Yes
No
No of pregnancies
Select
0
1
2
3
4
5
Do you have problems with erection or ejaculation?
Yes
No
Erectile Dysfunction
Anejaculation
Semen Analysis Report:
Date
Sperm count
(million per ml)
Motility
%
Morphology
Add More Entries
Previous
MEDICAL TESTS:
Hysterosalpingogram
(X-ray of the uterus and tubes)
Yes
No
RECORD 1
Date
Uterine Cavity
Normal:
Yes
No
More Details:
Right fallopian tube
Normal:
Yes
No
Fill:
Yes
No
Spill:
Yes
No
More Details:
Left fallopian tube
Normal:
Yes
No
Fill:
Yes
No
Spill:
Yes
No
More Details:
Add More Entries
Laparoscopy (telescope placed through the belly button to see inside your abdomen)
Yes
No
RECORD 1
Date
Uterus:
Normal:
Yes
No
More Details:
Right fallopian tube
Normal:
Yes
No
Fill:
Yes
No
Spill:
Yes
No
More Details:
Left fallopian tube
Normal:
Yes
No
Fill:
Yes
No
Spill:
Yes
No
More Details:
Adhesions:
Yes
No
More Details:
Endometriosis:
Yes
No
More Details:
Add More Entries
Hysteroscopy (telescope placed into the uterus through the vagina to see the inside of the uterus)
Yes
No
RECORD 1
Date
Uterine Cavity:
Normal?
Yes
No
More Details:
PolyP?
Yes
No
More Details:
Adhesions?
Yes
No
More Details:
Fibroid?
Yes
No
More Details:
Add More Entries
Hormonal blood tests:
FSH
Yes
No
Date
Result
Add More Entries
LH
Yes
No
Date
Result
Add More Entries
Prolactin
Yes
No
Date
Result
Add More Entries
TSH
Yes
No
Date
Result
Add More Entries
Other
Yes
No
Date
Result
Add More Entries
Previous
MEDICAL TREATMENT:
Ultrasonography Monitoring
Yes
No
Date
Any Success?:
Add More Entries
Clomiphene stimulation with intercourse
Yes
No
Date
Any Success?:
Add More Entries
Clomiphene stimulation with insemination (IUI)
Yes
No
Date
Any Success?:
Add More Entries
HMG stimulation with intercourse
Yes
No
Date
Any Success?:
Add More Entries
(IUI) without any stimulation
Yes
No
Date
Any Success?:
Add More Entries
Injectable HMG stimulation with insemination (IUI)
Yes
No
Date
Any Success?:
Add More Entries
In vitro fertilization (IVF)
Yes
No
RECORD 1
Date
Doctor:
Stimulation Protocol:
Downregulation with:
Superovulation with:
Dose of Hmg:
Days of Hmg:
Follicles grown:
E2(estradiol) level:
Eggs collected:
Endometrial thickness:
Embryos formed:
Embryos transferred:
Embryos frozen:
Beta HCG:
Pregnancy outcome:
Add More Entries
ICSI
Yes
No
RECORD 1:
Date
Doctor:
Stimulation Protocol:
Downregulation with:
Superovulation with:
Dose of Hmg:
Days of Hmg:
Follicles grown:
E2(estradiol) level:
Eggs collected:
Endometrial thickness:
Embryos formed:
Embryos transferred:
Embryos frozen:
Beta HCG:
Pregnancy outcome:
Add More Entries
Are there other pertinent test results, procedures or problems that have been identified?
My question (try to keep this as specific as possible, please!) to Doctor is
Previous
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