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History

The easiest way of talking to me is by email. I prefer email because this way you have a written record of my advise; and there is less scope for error or confusion. This is basic medical information which every infertile couple must know.

While you don't have to fill in all the information, please remember that the more the detail you provide and the better the question you ask, the better my answer will be.

This form comes to me, so you can rest reassured that your privacy and confidentiality are strictly maintained. I request you to get print out of this form – then fill it on hard copy and then fill on line.

General Details
Date (dd-mm-yyyy e.g. 31-07-1998)
Name of Wife
Name of Husband
Email Address
Please ensure that this is a valid email address (e.g., prakashbaroda@yahoo.com) you will not be able to read my reply if you make a mistake!!!
Please also make sure you can receive emails at this address - don't use a company email id which often blocks emails from unknown senders.
Where do you live?
(detailed address)
How long have you been married?
How long have you been trying to get pregnant?
How long have you been trying to get pregnant with a doctor's help?
Was it a General Gynecologist or an Infertility Specialist?
Why do you think you are not getting pregnant (your own diagnosis)?
Female History
Age
Date of Birth (dd-mm-yyyy e.g. 31-07-1998)
Height (ft)
Weight (kg)
Menstrual periods occur every days.
Are they regular?
For how many days do you bleed?
What are other bodily complains during menstruations? Describe one by one in detail
Have you ever had Pelvic Inflammatory Disease (PID)?
What pelvic surgeries have you had? Which year?
What were the findings?

Number of miscarriages (abortions). Which year? How many weeks pregnant were you?
Medical problems and current medications

(think of all medical problems start from head – eyes – nose – mouth ... up to feet.)
This is most important as I will go on asking details on each symptoms you have listed, while on call.
Male History
Age
Date of Birth (dd-mm-yyyy e.g. 31-07-1998)
Do you have problems with erection or ejaculation or reaching orgasm?
Sperm count million per ml.
  Motility %
Medical problems and current medications
(think of all medical problems start from head – eyes – nose – mouth ... up to feet.)
This is most important as I will go on asking details on each symptoms you have listed.
Medical Tests
Have you had:
Test Yes / No Date
(dd/mm/yyyy)		 Result
Hysterosalpingogram
( X-ray of the uterus and tubes) 		 Yes
 No
Laparoscopy(telescope placed
through the belly button
to see inside your abdomen)		  Yes
 No
Hysteroscopy (telescope placed
into the uterus through the vagina
to see the inside of the uterus)		  Yes
 No
Hormonal blood tests  Yes Please enter the values of blood test reports below.
 No
FSH  Yes
 No
LH  Yes
 No
Prolactin  Yes
 No
TSH  Yes
 No
Other  Yes
 No
Medical Treatment

Give details results, if applicable...

Ultrasound Monitoring
Clomiphene Stimulation
IUI
HMG Stimulation
In Vitro Fertilization (IVF)

Give details of IVF / ICSI results, if applicable.

Are there other pertinent test results, procedures or problems that have been identified?

Your question or queries: (try to keep this as specific as possible)
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