Patient Contact Information
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Last Name: * |
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Email: * |
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Phone: * |
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Mobile Phone |
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Address # 1: |
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Address # 2: |
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City: |
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State: |
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Zip / Country Code: |
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Country: |
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Pregnancies |
Have you had any pregnancies? |
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How many? |
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If yes did they result in Live birth or Miscarriage |
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Do you have any children |
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Please give details |
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Laparoscopy, Hysteroscopy or Aqua Scan |
Have you had a Laparoscopy, Hysteroscopy or aquascan? |
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Date |
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Please Give Findings |
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Health Issues |
Any Health issues for either partner |
Yes
No |
Please give details: |
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Fertility Treatments |
Have you had any fertility treatments? |
Yes
No |
Number of Cycles |
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If yes please give details of types of treatments undergone, egg numbers, level of fertilisation, embryos replaced, treatment outcomes: |
Cycle 1 |
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Cycle 2 |
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Cycle 3 |
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Cycle 4 |
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If considering egg donation please let us know the following |
Gender (Female) |
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Height: |
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Weight: |
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Blood Group |
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Build |
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Complexion |
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Eye colour |
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Hair colour |
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Hair Texture |
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Date of Birth |
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Gender (Male) |
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Height: |
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Weight: |
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Blood Group |
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Build |
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Complexion |
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Eye colour |
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Hair colour |
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Hair Texture |
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Date of Birth |
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Male Factor |
Semen Findings |
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If there is low sperm count, Mention count |
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Date of Report |
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Any Surgery done related to Infertilty |
Yes
No |
If Name & condition |
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Other |
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Your Infertilty Consultant in U.S. |
Please provide the name of your Doctor |
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Phone |
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E-mail |
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Address |
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Address #2 |
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City |
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State |
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Zip |
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Country |
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* Indicates required field. |