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Informed Choice - Questions you need to ask yourself

  • Are you able to use extended forms of communication like Email, Telephone and communicate with Past clients?
  • Have you asked questions, raised your concerns and fears?
  • How do you feel about how the Surgeon has addressed your questions?
  • Has your communication been open and honest?
  • Are you sure that you have realistic expectations?
  • Have you been made aware of the benefits and risks involved?

Date of Birth
Home Street Address
Email Address
Passport Nationality
Passport Number
Are you married?
Yes No
Spouse / Male Partner
First Name
Last Name
Date of birth
Home Street Address
Passport Nationality
Passport Number
Do you have a Gynecologist?
Yes No
If so, state the name of the Gynecologist
Contact email for Gynecologist
Do you have a General Practitioner?
Yes No
If so, state the name of the General Practitioner
Contact email for General Practitioner
Female Medical History
Reason for Treatment
Fertility Evaluation
Yes No
Recurrent Pregnancy Loss
Yes No
Yes No
What are expectations for visit?
What questions do you want answered
at this visit?
Do you have any personal ethical or religious objections to any of our tests or treatment such as insemination, in vitro fertilization, egg donation, sperm donation, masturbation to collect a semen sample etc ?
Yes No
Pregnancy Summary
Total number of all pregnancies
Number of miscarraiges (less than 20 weeks)
Number of ectopic / tubal prgnancies
Number of elective terminations (Abortions)
Number of full term deliveries
of these how many were live births
how many were still born
Any pregnancy with birth defects and explain
Menstrual History
Menstrual Cycle Pattern:
No Periods
Heavy Periods
Light Periods
Leeding between Periods
Spotting befor Periods
Number of days between the start of one period to the start of the next period
How many days bleeding do you have?
Dates of the 1st day of your last 2 menstrual period
1st Period
2nd Period
Age when you had your first period
Years old
Age when you first noticed:
Breast development
Pubic hair
Underarm hair
How many periods do you have per year?
Do you need medication to bring on a period?

Yes No
If you do not have periods, at what age did you stop having them?
Do you have severe cramping or pelvic pain with your periods?
Contraception History
Foam Jelly
Birth Control Pills
Never used Birth Control Pills
Injectable Contraception
(Depo Provera, Nuristerate)
Tubal Sterilization Procedure
Sexual History
How many times per week do you have intercourse?
times per week / None
Have you used over-the-counter ovulation kits to time intercourse
Yes No
Do you have pain with intercourse?
Yes No
Do you use lubrication ( K_Y jelly ) during intercourse?
Yes No
Have you had any of the following sexually transmitted diseases or pelvic infection?
Yes No

Pap Smear History
When was your last pap smear?

When was your last abnormal pap smear?
Have you undergone any procedure as a result of an abnormal pap smear?
Laser treatment
LEEP Procedure
Breast Screening History
Have you ever had a mammogram?
Yes No

Normal Abnormal

Do you perform breast self exams?
Yes No
Medical History
Please list any allergic reactions to medication you might have?
Please list any allergic reactions to food you might have?
Please list any medication you are currently taking, including over the counter medicines?
Do you take any herbal medicines / vitamins or health food supplements?
Do you have any medical problems?
Did you have Chickenpox or German measles?
Any childhood diseases?
Social History
How many caffeinated beverages (coffee, tea, soda) do you drink per day ?
Do you smoke? How many and for how many years?
Do you drink alcohol – how much per week and what ?
Do you use marijuana, cocaine or any other similar drugs ? explain
Do you exercise ? explain
Are you aware of any radiation exposure other than X-rays ? explain
Surgical History
Have you had any surgery ? explain and describe
Have you had anesthesia before? Please explain if there were any complications or problems
Family History
Are any of your parents living and if so, what age and if not, cause of death?
Are any of your siblings living and if so, what age and if not, cause of death?
Are any of your grandparents living and if so, what age and if not, cause of death?
Prior infertility testing and treatment
Have you had prior infertility testing or treatment?
if you have you had any of the following prior tests, please specify and give the results and date of tests:
Thyroid, Ovulation, FSH blood test, Hysterosalpinggogram HSG, Laparoscopy, Hysteroscopy, Progesterone Blood test, Proclactin
if you have you had any of the following prior infertility treatments, please specify and give the outcome and date of treatment:
Intrauterin insemination, Clomid with intercourse, Clomid with insemination, daily fertility drug injections with insemination, Complete in vitro fertilization cylces

I have read the terms and conditions above:
Yes No
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Please be assured that all electronic data received is treated with the strictest confidentiality.

Any medical or surgical advice provided through this web site service, even if intended to be accurate to the best of our knowledge, should be discussed with the surgeon before embarking on any treatment, medication or therapy.

Thank you for taking the time to complete this profile.


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