PMA-FR Form – Social Networks 2

Full Name*

Country of Residence*

Phone Number*

Email *

Are you married?*

Yes

No

Duration of infertility*

Is there a known cause?*

Is there a health problem for either partner?*

Yes

No

If yes, please provide details.

Female's Age?*

Do you have children?*

Yes

No

If yes, please provide details.

Have you had pregnancies?*

Yes

No

If yes, how many?

If yes, did they result in live births or miscarriages?

Have you had a laparoscopy or hysteroscopy?*

Yes

No

If yes, please specify the date.

If yes, please indicate the results.

Do you have regular cycles?*

Yes

No

If no, please specify the frequency and duration of the irregular cycles.

Have you had fertility treatments?*

Yes

No

If yes, please indicate the number of cycles.

Has a sperm analysis been performed?*er of cycles.

Yes

No

If yes, please mention the date of the report.

If there is a low sperm count, please mention the number.

Has the male partner had an operation related to infertility?*

Yes

No

If yes, please mention the details of the operation.

PMA-IVF Medical Form