Name in full (Surname first):
Age: Occupation:
Postal Address:
Telephone No.:
Referring doctor:
Name: Address: Qualification:
Married for years
Have you conceived in the past? Yes No
If yes, please answer the following questions:
No. of children born in chronological orders
Age Sex Living / Nonliving
1.
2.
3.
4.
No. of miscarriage:
Years Natural Artificial
Husband's Name:
Husband's Occupation:
Office Address:
Telephone No.
H/O Major illness suffered in the past.
Particularly: Tuberculosis Cardiac disease Hypertension Diabetes
H/O psychological disturbances in the past
H/O Major surgery particularly abdominal surgery
Information on conditions preventing pregnancy:
Is your menstrual cycle regular?
If the cycle is irregular do you take and medicine to bring the menstruation?
Have you taken any fertility drugs before?
Have you maintained basal body temperature chart before?
1. Do you have histology report (Lab report) of D&C operation?
2. Do you know if your fallopain tubes are open or blocked
If the answer is yes, tick the following:
Both the tubes are open
Both the tubes are blocked?
Left tube is blocked
Right tube is blocked
Do you have Laparoscope report?
Do you have Hystero salpingography report?
Have you had any tubal surgery in the past
3. Have you been treated for endometnosis?
4. What is in your opinion your husband's sperm count
5. Did you undergo IVF/GIFT/ZIFT previously?
