Clinic History Female

Clinical History Of The Female Partner

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CLINICAL HISTORY OF THE FEMALE PARTNER

**PLEASE FILL IN THIS FORM IN CAPITAL LETTERS**

Please leave blank any questions you do not understand or are not sure of how to answer.
We ask you to pay close attention when filling in this questionnaire, as your answers are very important. All information is confidential and will be considered as apart of your medical history.

PATIENT






MALE PARTNER



















1. CLINICAL HISTORY OF THE FEMALE PATIENT

**PLEASE FILL THIS FORM IN CAPITAL LETTERS**

Please leave blank any questions you do not understand or are not sure of how to answer.
We ask you to pay close attention when filling in this questionnaire, as your answers are very important. All information is confidential and will be considered as a part of your medical history.





2. FAMILY HISTORY:

Among the members of your family (parents, brothers and sisters, aunts and uncles, children, nieces and nephews), is there any history of








3. PERSONAL MEDICAL HISTORY (PAST OR PRESENT):












































4. MENSTRUAL CYCLE:










YesNo



YesNo




5. PREGNANCIES WITH DELIVERY (YEAR, PREGNANCY WEEK, COMPLICATIONS, MODE OF DELIVERY):


YesNo

PREGNANCIES WITH DELIVERY (YEAR, PREGNANCY WEEK, COMPLICATIONS, MODE OF DELIVERY):



YesNo




6. PREVIOUS FERTILITY TREATMENTS

CENTER YEAR PROCEDURE
(INDUCED OVULATION, INSEMINATION, IVF, ICSI, USE OF DONOR SPERM/EGGS, TRANSFER OF FROZEN EMBRYOS)
EMBRYOS
TRANSFERRED AND CRYOPRESERVED
OUTCOME




appointment