IVF MEDICAL FORM

PATIENT’S CONTACT

Name & Surname

Country of residence

Phone

Email

Age of the woman

Are you married ?

yes

no

Infertility

Duration of infertility

Do you have regular periods ?

yes

no

Is there a known reason for infertility ?

Does one of the partners have a health problem?

Please give details

FOR THE WOMAN: PREGNANCIES

Have you already been pregnant?

yes

no

How many times?

If Yes, did they yield to births or to miscarriages?

Do you have children?

yes

no

Please give details

FOR THE WOMAN: LAPARASCOPY, HYSTEROSCOPY

Have you done laparascopies or hysteroscopies?

Date of procedures

Please indicate the results

Fertility treatment

Have you already undergone fertility treatment?

yes

no

Number of cycles?

If Yes, please indicate the procedures done, number of ovocytes, level of fertility, embryo transfers, result of procedure for Cycle , Cycle 1 etc

FOR THE MAN

Search for sperm

If there is a low level of sperm, indicate the number

Medical report date

Procedure done for fertility treatment?

yes

no

If Yes, please indicate

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