Update cookies preferences

Patient’s Medical History

We’re thrilled to have you with us. To make sure we provide you with the best care possible, please take a moment to fill out the form below. Your input will help us get to know you better and tailor our services to your needs.

Thank you for choosing us for your fertility care. We look forward to assisting you on your journey!

    I consent to the Personal Data Consents*.

    DEMOGRAPHICS


    Type of the treatment you are interested in:

    What is your relationship status?

    Patient/s

    Female

    Name / Surname *
    Date of Birth *
    Address
    Mobile Number *
    Email *

    Male

    Name / Surname *
    Date of Birth *
    Address
    Mobile Number *
    Email *

    Female Personal history

    Height *
    Weight *

    Menstrual Cycle:
    Regular
    Irregular
    PCO
    Cycle characteristics

    No of prior pregnancies (up to 6):

    Previous gynecological operations
    Laparoscopies
    Hysteroscopies
    Appendicitis

    Other concomitant diseases-medical conditions
    Diabetes
    Hypertension
    Thyroid
    Cardiological disease
    Thrombophilia
    Others

    Are you currently on any medication or are you taking medication on a regular basis?

    Any known drug allergies?

    Do you smoke?
    Do you drink alcohol?

    Do you have any family history of:
    Premature ovarian failure (whether sister’s, mom’s or grandmom’s period stopped early)?
    Infertility
    Known cancers

    Other i.e fibroids, endometriosis, diabetes, thyroid disease

    Prior tests
    Attach files of priortest (if performed): All format possible, including pictures.

    HORMONAL TESTS (FSH, LH, E2, AMH, TSH, PRL)

    Glucose
    HSG – Tubes

    Previous IVFs?

    Date (month, year):
    Number of mature eggs:
    Number of embryos:
    Number of embryos transferred:
    Day of transfer (3rd or 5th):

    Male Personal history

    Height *
    Weight *

    Could you support us with the list of these conditions to choose from?

    Any previous surgeries?

    Are you currently on any medication or are you taking medication on a regular basis?

    Do you smoke?
    Do you drink alcohol?

    Any pregnancies (with same or previous partner)?

    Do you have history with infertility with another partner in the past?

    Any history of infection or trauma in the genital area, heat, or chemical exposure in the work environment?

    Do you have Family history of:
    Subfertility dad or brother:
    Any known cancers and what kind?
    Other

    Semen analysis


    I understand the above information and certify that this information is true, accurate and complete to the best of my knowledge.

    The information above is confidential. It is to be exclusively used for the legal person to whom they are addressed. Assisting nature has a policy for the proper use of all sensitive personal data and in accordance with the permission of the DPA sensitive personal data.

    Espa
    Espa
    DYPA
    Accessibility by WAH