First language
Full name and surname
Date of birth Age
Blood type Weight Height
Citizenship
Home Address
Tel. Home Tel. Office Cellular
E-mail
Referred by
Family Physician
Address Tel.
At what age did your menstrual periods start?
Do you still have periods? Yes No
Date of last period
Are you menopausal? Yes No
Do you take hormone replacement therapy? Yes No
Are your periods regular? Yes No
Date of last period How long did it last?
How many days between your periods?
Do you have very painful periods?
Do you have any bleeding in between periods? Yes No
Explain
Do you suffer from a vaginal discharge? Yes No
Do you experience discomfort during intercourse?
When was your last PAP smear?
Have you ever had an abnormal PAP smear result? Yes No
Do you use contraception? Yes No
What type?
Have you ever made a hysterosalpingography test? Yes No
Explain results
Have you ever made a serology test (hepatitis B, C, HIV, VDRL (syphilis)? Yes No
Explain results and date of the last test
Have you ever made a hormone profile test? Yes No
Do you have any problems with passing urine? Yes No
Do you have any problems with your bowels? Yes No
Other Gynaecological history
Number of pregnancies None 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Dates
Number of miscarriages None 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Number of termination of pregnancies: None 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Number of children None 1 2 3 4 5 6
Number of children from this relationship None 1 2 3 4 5 6
Are you currently breastfeeding? Yes No
Do you have any allergies? Yes No
Do you have any present medical condition? Yes No
Have you had hospitalisation for any medical condition? Yes No
Are you currently taking any medication (prescribed or over the counter)? Yes No
Have you had previous operations? Yes No
Are there any specific medical conditions within your family? Yes No
What is your occupation?
Do you smoke? Yes No
How many per day?
Do you drink alcohol? Yes No
How often?
Do you have children from other relationships? Yes No
Number
Have you ever made a serology test (hepatitis B, C, HIV, VDRL) ? Yes No
Have you ever made a semen test? Yes No
How long have you been trying to conceive?
Please describe infertility problem
Please describe investigations performed and results of these
Please describe infertility treatments (when, what, and detailed results)
What treatment are you planning to undergo?
Do you require donor sperm?
Any other information?
Please send copies of all requested test results to us by fax or email.
