Patients Form Pre‑IVF Patient Questionnaire PATIENT DETAILS Name Age -select- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 Nationality Spouse Name: Nationality Mobile No. Email Married for (years) -select- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 Language FERTILITY HISTORY Trying to conceive for: <1 year 1–2 years >2 years Previous pregnancy No Yes No. of Pregnancies: -select- 1 2 3 4 5 6 7 8 9 10 Pregnancy Outcome Baby Born Miscarriage Ectopic Pregnancy Previous fertility treatment: No Medicines IUI IVF MEDICAL HISTORY (Female) Any medical illness? No Diabetes High Blood Pressure Thyroid disease Asthma Heart disease Blood disorders Genetic disorders: Self Family No known medical problems Previous surgery? No Yes Any drug or food allergies? No Yes Are you taking any medicines or vitamins now? No Yes LIFESTYLE Smoking / Vaping: No Yes Alcohol: No Yes Regular Exercise: No Yes Menstrual & Gynecological History Periods regular? Yes No Not sure Average cycle length (days) Painful periods: Yes No Heavy bleeding: Yes No Known condition: PCOS Fibroids Endometriosis Thyroid None MEDICAL HISTORY (Male) Any medical illness? No Diabetes High Blood Pressure Thyroid disease Asthma Heart disease Blood disorders Genetic disorders Self Family No known medical problems Previous surgery? No Yes Any drug or food allergies? No Yes Are you taking any medicines or vitamins now? No Yes LIFESTYLE Smoking / Vaping: No Yes Alcohol: No Yes Regular Exercise: No Yes Use of Steroids: No Yes MALE PARTNER (if applicable) Semen analysis done? Yes No Not sure Specify: History of surgery Infection (mumps, STI) Varicocele Erectile or ejaculation problems I understand IVF success is not guaranteed and treatment may involve medicines and procedures. DECLARATION I confirm that the above information is true and complete to the best of my knowledge. Patient Name: Date Submit Form
