Appointment

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Female Partner Information

Your Name *

Your Surname *

Date of Birth *

Phone Number *

Your Occupation

City/Country You Live In

Male Partner Information

Spouse's Name

Spouse's Surname

Date of Birth

Phone Number

Lifestyle

Do you smoke? (Female Partner)

Do you smoke? (Male Partner)

Medical Details (Female Partner)

Menstrual Cycle

Regular

Irregular

No periods

Periods with medication

Have you ever been pregnant?

Has HSG (Hysterosalpingography) been performed?

Chronic Diseases

Previous Surgeries

Any Infectious Diseases?

Medications Used

Medical Details (Male Partner)

Has a semen analysis been performed?

Is there varicocele?

Chronic Diseases / Surgeries

Any Infectious Diseases?

Treatment History

Have you ever tried IVF?

Yes

Additional Notes / Complaints