Best IVF Treatment Clinic, Care IVF, Kolkata

PERSONAL INFORMATION

Wife Name

Husband Name

Email Address

Address

City of Residence

Country

PinCode

Telephone Number (Residence)

Mobile Number

Married Since (Year/s / Month/s)

How long have you been trying to get pregnant?

How long have you been trying to get pregnant with doctor's consultation?

Doctor can be categorised as

Reason for Infertility (Why do you think you are not getting pregnant?)

FEMALE HISTORY

Age

Date of Birth

Height (ft & in)

Weight (Kg.)

Menstrual periods occur every

Are they regular?

Yes No

For how many days do you bleed?

Have you been told you have endometriosis?

Yes No

How was the diagnosis made?

When?

Have you ever had pelvic inflammatory disease (PID)?

Yes No

How was the diagnosis made?

When?

Have you ever had pelvic surgery

Yes No

Name of Surgery

Year

Findings

Add More Entries

Name of Surgery

Year

Findings

hdnPelvicSurgery

No. of Pregnancies with this partner

No. of Pregnancies with previous partner

Have you ever had a miscarriage? (abortions)

Yes No

No. of Miscarriage

Did you have tubal(ectopic) pregnancies?

Yes No

No of pregnancies

Are there any live births?

Yes No

No of live births

Medical problems and current medications of female partner

MALE HISTORY

Age

Birth Date

No. of Pregnancies with previous partner

Do you have problems with erection or ejaculation?

Yes No

Erectile Dysfunction

Anejaculation?

Semen Analysis Report

Date

Sperm Count

Motility

Morphology

Add More Entries

hdnSemen

Medical Test

Hysterosalpingogram (X-ray of the uterus and tubes)

Yes No

hdnHysterosalpingogram

Second Opinion Form

Need Our Help ? Please fill in the Second Opinion Form

PERSONAL INFORMATION

FEMALE HISTORY

MALE HISTORY

Semen Analysis Report

Medical Test

Record1

Record2

Accreditations

Care IVF Lansdowne

Care IVF Salt Lake

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