Surgeon and Safari - Infertility Medical History Form

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"I think you provide a superb service of which I'm sure you're justifiably proud. I'm most grateful to you for making it all happen so effortlessly."

Susan

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?

Name
Surname
Date of Birth
Occupation
Home Street Address
Country
Telephone
Email Address
Passport Nationality
Passport Number
Are you married?	Yes No
Spouse / Male Partner
First Name
Last Name
Date of birth
Occupation
Home Street Address
Country
Telephone
Passport Nationality
Passport Number
Doctors
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
Other	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:	Regular Irregular 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
None
Condoms	-
Diaphragm	-
IUD	-
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?	Normal Abnormal
When was your last abnormal pap smear?
Have you undergone any procedure as a result of an abnormal pap smear?	Colposcopy Cryosurgery Laser treatment Conization LEEP Procedure
Breast Screening History
Have you ever had a mammogram?	Yes No
Results?	Normal Abnormal Results explanation -
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?	Yes
Do you drink alcohol â€“ how much per week and what ?	Yes
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
IT IS IMPORTANT TO READ OUR TERMS AND CONDITIONS BELOW Terms & Conditions ------------------------------ -------------------------------------- Surgical Recuperation Accommodation Package -------------------------------------- Surgeon and Safari has its own unique private home situated in an up market residential area, offering private rooms in both a main house and a separate cottage, allowing the time to rest and heal in a truly comfortable yet personalized home from home, with experienced staff ( living on the property ) taking care of pre and post operative needs offering an environment of wellness. All rooms are private en suites offering privacy if needed: Beds have quality bed linen and non allergic down pillows and duvet Rooms have standard in room amenities ( hand creams, shampoo ) together with specialized post surgery amenities. Cost Estimate: -------------------------------------- The cost estimate for recuperation is quoted in SA Rand and subject to exchange rate fluctuations. Certain terms and Conditions apply. Includes: -------------------------------------- Accommodation Package Room - Personal Assistant (A friend away from home) to accompany you to all your medical appointments and surgery Transport for return airport transfers and medical appointments. Detailed Itinerary - scheduling travel, booking medical appointments Support and assistance before and during recuperation with full medical concierges services - Hospital admission and discharge Meals Laundry Refreshments Excludes: -------------------------------------- Â· Professional tour guides are available. Â· Shopping trips arranged when needed. Â· Thai Massage and Reflexology offered in room during recuperation Â· Fruit Acid Peels offered in room during recuperation Â· Arrange appointments for hairdresser and other beauty treatments . Safaris Options. Additional expenses not specified. Return air ticket to South Africa. Payment Terms: -------------------------------------- Payment for Accommodation Package to be made in full as per Pro Forma Invoice and paid to Surgeon and Safari via bank Transfer in order to confirm accommodation and services Any changes made after confirmation of your booking will be rescheduled if needed and / or adjusted and refunded accordingly Any bookings confirmed and not taken up will be subject to cancellation fees. -------------------------------------- Surgery - -------------------------------------- Please note that your decision to proceed with surgery will be made in consultation between yourself and your selected surgeon Surgeon and Safari is a facilitation company and offers you a full medical concierges service and are not qualified to make any medical comment nor offer medical advice or suggested treatment / procedures, these need to be discussed with your surgeon. Medical Evaluation: -------------------------------------- The fee quoted by Surgeon and Safari will be confirmed after further medical evaluation by the surgeon based on the medical history and requirements forwarded by yourself as requested and forwarded to the Surgeon After medical feedback from the surgeon we will be glad arrange a telephonic consultation with the surgeon prior to making a decision regards to your travel We encourage you to ask questions using email or the telephone and will put you in touch with past clients as we believe that you need to make an educated choice. Both you and the surgeon are under no obligation until after your pre operative consultation. Terms Surgeon & Safari remind you that all cosmetic surgery carries a risk, has limitations which could include disappointment with the results. You should agree about the anticipated outcome of your surgery and concur about your expectations of the results. You should discuss alternative treatments and thoroughly understand the risk of the procedures If any dispute may arise the surgeon is only liable if litigation takes place in South Africa, under South African Law. Any medical or surgical advice provided through the Surgeon & Safari web site and service, even if intended to be accurate to the best of our knowledge, should be discussed with the Surgeon. Always seek advice from your Surgeon before embarking on any treatment, medication or therapy or agreeing to any surgery. Cost Estimate - Surgery: -------------------------------------- The cost estimate is to be confirmed by the surgeon at your pre op consultation prior to surgery. The cost estimate is subject to exchange rate fluctuations, Certain terms and Conditions apply Includes: -------------------------------------- The cost is all-inclusive whilst in South Africa for selected procedure: The surgeon, specialist anesthesiologist, and private clinic/hospital stay for the required procedure with 24 hours nursing facilities, all theatre charges, medication whilst in hospital, pre and postoperative consultations in South Africa and non-refundable administration fee, for the selected procedures. Medical evaluation, Email correspondence and Telephonic consultations. Pre and Post operative instructions for your selected procedures. Detailed Itinerary for pre and post operative consultations. Excludes: -------------------------------------- Any additional medical expenses that might have incurred for the safety of your health as a result of unforeseen complications Ã� please discuss with the surgeon. Insurance. Additional procedures. Payment Terms: -------------------------------------- Non Refundable Administration Fee charged as a deposit to secure your booking. Deposit payable to Surgeon & Safari via bank transfer as indicated on the pro forma invoice and will be deducted from the final account payable to the surgeon. Balance of the fee payable directly to the surgeon at your pre operative consultation Payment can be made in Cash or via valid Visa, Master and Amex Credit Card Any changes made to booked medical procedures which affect the costs initially quoted and / or paid will be reconciled, adjusted and payable or refunded with your final Surgeon Account If for any medical or unforeseen circumstances your surgery needs to be cancelled the costs paid will be reconciled, adjusted and refunded accordingly.
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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