PERSONAL DETAILS
Date*
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
/
MM
Jan
Feb
Mar
Apr
May
June
July
Aug
Sep
Oct
Nov
Dec
/
YY
2008
2009
Name of wife *
Name of Husband *
Email Address *
Residential Address *
Married Since
(No. of Years)
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
Trying to get pregnant Since
(No. of Years)
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
FEMALE HISTORY
Age
Menstrual periods occur every
Days
Are they regular?
Yes
No
History of Endometriosis
Yes
No
History of pelvic inflammatory disease (PID)
Yes
No
Pelvic surgeries done in past?
Yes
No
Which year?
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
/
MM
Jan
Feb
Mar
Apr
May
June
July
Aug
Sep
Oct
Nov
Dec
/
YY
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
Findings of the Surgery?
Number of past pregnancies
Last pregnancy Year
Number of miscarriages
(abortions)
Which year?
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
/
MM
Jan
Feb
Mar
Apr
May
June
July
Aug
Sep
Oct
Nov
Dec
/
YY
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
How many weeks pregnant were you?
weeks
Number of tubal (ectopic) pregnancies
Last Miscarriage
Number of live births
Last Live Births
Medical problems / History?
Currently medications of female partner
MALE HISTORY
Age
Do you have problems with erection or ejaculation? Describe
Sperm count
million per ml.
Motility
%
Male medical problems and current medications. If you have an abnormal semen analysis report, please enter the details here.
Provide as much detail as you can, of your last report.
IVF / ICSI results
Give details of IVF / ICSI results, if applicable.
Stimulation protocol used
Follicles grown
Embryos formed
Embryos frozen
Are there other pertinent test results, procedures or problems that have been identified?
My question to Dr Firuza Parikh is?
(try to keep this as specific as possible)
