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Patient’s Medical History #2

We are very pleased to have you with us. Please complete the form to help us become acquainted.

    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
    Marital status
    Mobile Number *
    Email *

    Male

    Name / Surname *
    Date of Birth *
    Address
    Marital status
    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?
    If yes, please specify:

    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
    What kind if yes?
    Other i.e fibroids, endometriosis, diabetes, thyroid disease
    If yes, please specify:

    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?
    If yes, how many?

    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?
    If yes, please specify:

    Are you currently on any medication or are you taking medication on a regular basis?
    If yes, what kind of medication?

    Do you smoke?
    Do you drink alcohol?

    Any pregnancies (with same or previous partner)?
    Year of pregnancy:

    Partner

    Way of conceptions:

    Outcome:

    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