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eConsult Detail

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)
Laparoscopy
Hysteroscopy
Hormonal blood tests
FSH
LH
Prolactin
TSH
AMH
Other
MEDICAL TREATMENT YES / NO HOW MANY DATE ANY SUCCESS
Ultrasound monitoring
(IUI) without any stimulation
(IUI) with any stimulation (CC/HMG)
In vitro fertilization (IVF)
IVF-ICSI
Assisted Hatching
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? :