Documents and Forms

1Patient Personal Details

2Medical Conditions, Surgeries & Medications

3Female Specific Information

4Male Specific Information

5Allergies & Social Risks

Name*

First Last

Date of Birth*

Gender*

Please select your gender at birth

Female

Male

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Approximately when did you start trying to conceive?

(estimate month & year started)

Height (cm)

Weight (kg)

Do you have a partner?*

Yes

Partner's Details

Partner Name

Please enter partners name if applicable

First Last

Partners Date of Birth

Enter if applicable

Partner's Gender*

Please select gender at birth

Female

Male

Female Specific Information

Date of Last Menstrual Period (LMP)

Average Cycle Length

Average number of days in your cycle

Minimum Cycle Length

Minimum number of days in your cycle

Maximum Cycle Length

Maximum number of days in your cycle

Date of Last Pap Smear

Pap Smear Results

ie Normal

Have you ever been pregnant?

Yes

Pregnancy Details

Pregnancies with Current Partner

Enter number in appropriate box(es)

Full Term (>37 weeks)

Pre-Term (<37 weeks)

Biochemical

Miscarriage (<12 weeks)

Miscarriage (12-20 weeks)

Termination

Ectopic

Pregnancies with Previous Partner

Enter number in appropriate box(es)

Full Term (>37 weeks)

Pre-Term (<37 weeks)

Biochemical

Miscarriage (<12 weeks)

Miscarriage (12-20 weeks)

Termination

Ectopic

Details of Babies Delivered

Born after 20 weeks

Date

Conception Type (ie natural, ivf or insemination)

Outcome (ie Live Birth, Still Birth)

Delivery (ie c-section, natural)

Gender

Name

Previous Fertility Treatment

Please give details of any other Fertility treatment you've had at any other clinic

Year

Clinic

Treatment Type (ie IVF, PGD)

Outcome (ie cancelled, biochemical, pregnant etc)

Male Specific Information

Do you have children with your current partner?

Yes

Do you have children with a previous partner?

Yes

Details of Children born to Previous Partner Only

Do not include children born to your current partner

Date

Conception Type (ie natural, ivf or insemination)

Outcome (ie Live Birth, Still Birth)

Delivery (ie c-section, natural)

Gender

Name

Date of Last Semen Analysis

Where did you have the Semen Analysis?

Name of Pathology Centre or Clinic

Do you have any problems with ejaculation

If yes, please request to speak with a nurse

Yes

Do you foresee any problems using our on-site collection room?

Is yes, please request to speak with a nurse

Yes

DOCUMENTS

MEDICAL HISTORY FORM

Partner's Details

Female Specific Information

Pregnancy Details

Male Specific Information

Allergies & Social Risks

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Documents and Forms

DOCUMENTS

MEDICAL HISTORY FORM

Partner's Details

Female Specific Information

Pregnancy Details

Male Specific Information

Allergies & Social Risks

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