Medical Form - Cyprus IVF Clinic

PERONAL INFORMATION

YOUR NAME

First

Last

ADDRESS

EMAIL*

MOBILE/PHONE NUMBER:*

DATE OF BIRTH:*

BLOOD TYPE:

WEIGHT (kg):

HEIGHT (cm):

EMERGENCY CONTACT

NAME AND RELATIONSHIP:

CONTACT INFORMATION:

Other

If any allergies, please provide details together with current medication(s) you are taking related to this.

GENERAL MEDICAL HISTORY

Do you smoke?

Yes

No

If yes, please write the number of cigarettes you smoke daily.

Do you have any medical related illnesses, disabilities or infirmities that have required the regular care of a physician over the past 12 months?

Yes

No

If so, please describe in general terms:

What illnesses/medical conditions have you had in the past 5 years? (Leave empty if none).

Have you been hospitalised in the last 5 years? (If yes, for what reason? If no, leave empty).

Have you ever had a general anaesthetic? (If yes, did you experience any difficulties? If no, leave empty).

REPRODUCTIVE HISTORY

Do you have regular periods?

Yes

No

How long is your normal cycle?

Please write the start dates of your last three periods.

Please describe the history of your previous pregnancies (live birth, miscarriage, ectopic pregnancy etc.)

How long have you been trying to conceive?

Have you ever used any kind of contraception? If yes, when did you use it and how long did you use it for?

Have you ever had any gynecological problems such as fibroids, endometriosis, ovarian cyst, abnormal cervical cytology? (If yes, please describe in detail).

Have you ever had any gynecological surgery?

Yes

No

Have you ever undergone any assisted reproductive technique (e.g. intrauterine insemination, in vitro fertilization) to get pregnant?

Yes

No

If you have tried IVF before, how many successful and/or unsuccessful tries have you had?

FERTILITY TEST RESULTS

Have you had any fertility tests within the past 6 months?

Yes

No

If yes, which date(s):

And if yes, please complete the below section with its results.

Hormone Blood Tests Results for:

LH (luteinising hormone):

AMH (anti-mullerian hormone):

TSH (thyroid stimulating hormone):

Prolactin:

Ultrasound Scan:

Trans-vaginal Antral Follicle Count (to count the number of follicles in each ovary):

Any other relevant information:

Please type the characters*

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