1. Step
A B AB 0           RH - RH +
Fair Medium Dark Ebony

Black Brown Green
Blue Hazel Other

Miyop
Hipermetrop
Astigmat
Black Brown Blonde Red Other
Straight Wavy Curly           Thin Thick

Right Hand Left Hand

Literate Grammar School Middle School High School University PhD & Above

2. Step
A B AB 0           RH - RH +
Fair Medium Dark Ebony

Black Brown Green
Blue Hazel Other

Miyop
Hipermetrop
Astigmat
Black Brown Blonde Red Other
Straight Wavy Curly           Thin Thick

Right Hand Left Hand

Literate Grammar School Middle School High School University PhD & Above

3. Step









Google Whatclinic Friend (Please type his/her name) 

Other (Please describe it)          

4. Step

Female Prtner's History








Yes No






Yes No


Acne
Excessive hair growth
Breast disease or Breast discharge
Uterine fibroids
Endometriosis
Ovarian Cysts
Polycystic Ovarian Syndrome (PCOS)
Genital Herpes (HSV)

Genital Warts (HPV)
Gonorrhea
Chlamydia
Syphilis
Pelvic inflammatory disease (PID)
Thyroid dysfunction
Cardiovascular / Heart disease
High blood pressure

Mitral valve polapse (MVP)
Blood clot
Diabetes
Asthma/Lung disease
Hepatitis
Liver Disease
Kidney disease
Gastrointestinal disease


5. Step


Yes No




Which of the following tests have you done?



















Appendectomy
Caesarean section
Laparoscopy
Removal of an ovarian cyst or mass

Removal of endometriosis
Removal of pelvic scar or adhesions
Removal of a uterine polyp or other defect
Removal of a fibroid

Hysteroscopy
Dilatation and Curettage (D&C)
Surgery on your fallopian tubes
Tubal ligation






Yes No



Yes No


6. Step


Yes No


Yes No


Yes No


Yes No



Have you had IVF or IVF- ICSI ? IF so, please provide details below (The last three IVF results are sufficient)





7. Step

Male Partner's Medical / Surgical History




Has your male partner had a hernia repair?

Has your male partner had an injury to his testicles?

Was he treated at a hospital for the injury?



Has your male partner had a varicocele repair?  When?



Has your male partner had a vasectomy reversal or repair?  When?



Yes No



Yes No



Yes No






Clomiphene (Clomid, serophene)
GnRH agonist (Lupron, synarel, zoladex)
Bromocriptine (Parlodel, dostinex)
HCG (Profasi, pregnyl)

Viagra
Proceed
Steroids (Prednisone, dexamethasone)
Testosterone

Other, specify :

8. Step

Male Partner's Medical History




Yes No


Yes No




Yes No



Yes No


Yes No


Yes No


Male Partner's Sexual History



Yes No



Yes No


Yes No


Yes No



Yes No


Male Partner's Family History



Yes No


Yes No


Yes No


Yes No


Male Partner's History of Fertility Therapy



Yes No


Yes No