Please take a print out of the form & fill it up with your doctor's help. *All detail inputs are compulsory. *Patient Name: *Husband's Name: *E-mail: *Country of residence: How long have you been married (Years): How long have you been seeing an Infertility expert (Years): Are you aware of a specific reason for not getting pregnant: Female History: Age:Birth Date: Height:Weight: Menstrual days occur every: For how many days do you bleed: Do you suffer from Endometriosis/ PCOD: Have you had any miscarriage: Do you have a history of pelvic disease: Are you a diabetic: Do you suffer from thyroid disease: Any known medical problem: Do you drink/ smoke/ use recreational drugs: Male History: Age:Birth Date: Height:Weight: Do you have any sexual or medical problems: Any known medical problem: Sperm Count : million per ML.Motility:%Morphology: Do you drink/ smoke/ use recreational drugs: Medical Test Report: MEDICAL TESTS YES / NO DATE RESULT Hysterosalpingogram ( X-ray of the healthy tubes) Yes No Laparoscopy Yes No Hysteroscopy Yes No Hormonal blood tests Yes No FSH Yes No LH Yes No Prolactin Yes No TSH Yes No AMH Yes No Other Yes No MEDICAL TREATMENT YES / NO HOW MANY DATE ANY SUCCESS Ultrasound monitoring Yes No (IUI) without any stimulation Yes No (IUI) with any stimulation (CC/HMG) Yes No In vitro fertilization (IVF) Yes No IVF-ICSI Yes No Assisted Hatching Yes No Give details of IVF / ICSI results, if applicable. Stimulation protocol used No. Of eggs retrieved Embryos formed Embryos transferred Embryos frozen Quality of Embryos : The day of transfer : Any Specific problems? : Your Specific query? : Submit