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Apollobramwell.com

PATIENT APPLICATION FORM

General Information

Date__________________ How did you hear about our Service? ________________________ Name _________________________________Identity Number _________________________ Home Phone _______________________________Work Phone ________________________ Cell Phone ______________________ Email Address ________________________________ Address _____________________________________________________________________ City ________________________ State ____________ Zip/Postal Code _________________ Occupation _____________________________ Employer ____________________________ Male Partner Name __________________________Identity Number ____________________ Home Phone ____________________ Work Phone _________________________________ Cell Phone ______________________ Email Address _______________________________ Address ____________________________________________________________________ City ________________________ State ____________ Zip/Postal Code _________________ Occupation ____________________________ Employer ______________________________ SOCIAL HISTORY
Are you married? ________How long have you been married? __________________________ How long have you been trying to get pregnant? _____________________________________ How long have you been trying with a doctor's help? __________________________________ Was the doctor a Gynecologist or a Reproductive Endocrine / Infertility Specialist? __________ How many times a month do you have intercourse? __________________________________ Does either partner smoke? _____________ How much? _____________________________ Does either partner use recreational drugs? ______ Which ones? _______________________ FEMALE HISTORY
Age________________ Birth date _________________ Height_________ Weight__________ Menstrual periods occur every ________ days. Are they regular? _______________________ For how many days do you bleed? _________ Do you have endometriosis? _____________________________________________________ Do you have any medical problems? ___________ (if YES) Give details, including current ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Do you have any medication allergies?___________(if YES) Which medications?______ Have you ever had pelvic inflammatory disease (PID)?_________ (if YES) What pelvic surgeries have you had? _______________________________________________________ Number of pregnancies with this partner and outcomes _______________________________ Number of pregnancies with a previous partner _____________________________________ Number of miscarriages _________ Number of abortions _____________________________ Number of tubal pregnancies ___________ Number of live births _______________________ MALE HISTORY
Age_________ Birth date _________________ Height______________ Weight___________ Number of pregnancies with a previous partner _____________________________________ Do you have problems with erection or ejaculation? __________________________________ Do you have any medical problems? ____________ Give details, including any medications: ___________________________________________________________________________ Do you have any medication allergies? Which medications?____________________________ TESTING AND TREATMENT HISTORY
Have you had?
Test

Hysterosalpingogram (dye test)


Day 3 FSH test (blood test)


AMH, anti-mullerian hormone
(blood test)


Antral follicle counts of ovaries


Laparoscopy


Hysteroscopy


Semen analysis

Procedure

How many?
Any success?
intercourse
Clomiphene stimulation with
insemination

Injectable FSH stimulation with
intercourse

Injectable FSH stimulation with
insemination

Inseminations without any drug
stimulation
In vitro fertilization

In vitro fertilization with ICSI

In vitro fertilization with donor eggs
OTHER
Is there anything else we should know about your case?
Are there other pertinent test results, procedures or problems?
Are there specific questions you would like address

Source: http://www.apollobramwell.com/uploads/IVF_Application_Form.pdf

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