Welcome to our clinic.
Please complete all sections of this form to the best of your ability. Your confidential answers
will be reviewed by our nursing and medical staff and will ensure you get the best possible
care.
FEMALE PATIENT
YOUR PARTNER
Full name
Forename Surname
Forename Surname
Date of birth
day / month / year
day / month / year
Address
Height :
Weight:
Height :
Weight :
Work Tel:
Home Tel :
Work Tel:
Cell 2:
Cell 1:
Cell 2:
Occupation
Ethnicity
Home Tel:
Cell 1:
Email
@
How did you hear about us?
Friend
@
Doctor
Newspaper
TV
Radio
Internet
How many years have you being trying for a pregnancy together? _________ years
Have either of you had fertility difficulties with a previous partner?
No previous partners. Please go to next question
Yes, details_____________________________________________________________
Have you ever had any pregnancies?
no – I have never had a pregnancy. Please go to next question
yes – I have had _____ pregnancies, please give details by completing table below
YEAR
Type of pregnancy – circle as appropriate
year
year
year
year
year
year
Termination / miscarriage / ectopic / live birth / stillbirth
Termination / miscarriage / ectopic / live birth / stillbirth
Termination / miscarriage / ectopic / live birth / stillbirth
Termination / miscarriage / ectopic / live birth / stillbirth
Termination / miscarriage / ectopic / live birth / stillbirth
Termination / miscarriage / ectopic / live birth / stillbirth
Pregnancy
ended at __
months
Pregnancy was
with current
partner
months
months
months
months
months
months
Yes / no
Maraval Clinic:
1B Rookery Nook, Maraval, Port of Spain.
Medical Associates Hospital Clinic: Abercromby Street, St Joseph
Email [email protected]
Website www.TrinidadIVF.com
Any other
information
Yes / no
Yes / no
Yes / no
Yes / no
Yes / no
TEL: 868 622 8869, 868 622 6595
TEL: 662 8344, 222 8341
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QUESTIONS FOR FEMALE PATIENT
When was your last period?
day/month/year
How many days do your periods last for?
How regular are your periods?
always regular
usually regular (occasionally 1-3 days early or late)
mostly regular (sometimes skip a month)
not regular – I often skip 1-3 months
completely irregular – no pattern at all
I have had no periods for over a year
What is the average number of days from the start of one period through to the first day of your
next period (for most women this is 25-35 days)? ____________ days
Do you suffer with any of the following (please circle as appropriate)?
Moderate period pain
Yes / No
Severe period pain
Yes / No
Pain with sexual intercourse
Yes / No
Bleeding after sexual intercourse
Yes / No
Bleeding at times other than your period Yes / No
Vaginal discharge that is not normal
Yes / No
Discharge from the breasts
Yes / No
When was your last PAP smear? day/month/year OR
I have never had a PAP smear
Have you had any surgery? If yes, please list dates and details
YEAR
Type of surgery – if known
Doctor (if known)
Any other information
year
year
year
year
Please list details of all drugs you are currently taking or have stopped in the last 3 months (drug
name, drug dose):
Are you allergic to any drugs? No / Yes, drug(s) name
Does anyone in your family have twins, triplets or multiple births? Yes / No
Maraval Clinic:
1B Rookery Nook, Maraval, Port of Spain.
Medical Associates Hospital Clinic: Abercromby Street, St Joseph
Email [email protected]
Website www.TrinidadIVF.com
TEL: 868 622 8869, 868 622 6595
TEL: 662 8344, 222 8341
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Please tick (√) if you have ever had any of the following medical conditions:
Anaemia
Syphilis
Sickle cell anaemia
Epilepsy or convulsions
Other blood illness
Gonorrhoea
Asthma
Herpes
Thyroid disease
TB
HIV or AIDS
Heart problem
Hepatitis B
Stroke
Hepatitis C
Liver disease
Any other medical condition, details:
High blood pressure
Diabetes
Abnormal PAP smear results
Endometriosis
Chlamydia
Migraines
You were born with an abnormality
Ovarian cysts
Do you have any medical conditions that run in your family? No / Yes
If yes – please give details
Are you a smoker?
yes
no
Do you drink alcohol?
daily
occasionally
Have you ever used recreational drugs?
rarely
never
no
Yes, details _____________________________________________________________________
Have you been exposed to excessive chemicals, pesticides, drugs, gases or radiation?
no
Yes, details _____________________________________________________________________
Please tick if you or your partner have ever had any of the following fertility treatments or tests:
√
Year of treatment and any details or results
Tube x-ray (HSG)
Clomiphene fertility tablets
Fertility injections
IUI (insemination)
IVF
Sperm test
Maraval Clinic:
1B Rookery Nook, Maraval, Port of Spain.
Medical Associates Hospital Clinic: Abercromby Street, St Joseph
Email [email protected]
Website www.TrinidadIVF.com
TEL: 868 622 8869, 868 622 6595
TEL: 662 8344, 222 8341
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QUESTIONS FOR MALE PARTNER
Do you have any children? Yes/No
If yes, how many children do you have? ___________ ages:_____________________
Are you a smoker?
Do you drink alcohol?
No
Yes
Daily
Have you ever used recreational drugs?
occasionally
rarely
No
never
Yes, details:
Have you been exposed to excessive chemicals, pesticides, drugs, gases or radiation?
no
Yes, details _____________________________________________________________________
Please list details of all drugs you are currently taking or have stopped in the last 3 months
(drug name, drug dose):
Are you allergic to any drugs? No / Yes, drug(s) name
Do you have any medical conditions that run in your family? No / Yes
If yes – please give details
Have you had any surgery? If yes, please list dates and details
YEAR
year
year
Type of surgery – if known
Doctor (if known)
Any other information
Please tick if you have ever had any of the following medical conditions:
Anaemia
Syphilis
Sickle cell anaemia
Epilepsy or convulsions
Other blood illness
Gonorrhoea
Asthma
Herpes
Mumps
TB
HIV or AIDS
Heart problem
Hepatitis B
Stroke
Hepatitis C
Liver disease
Any other medical condition, details:
Maraval Clinic:
1B Rookery Nook, Maraval, Port of Spain.
Medical Associates Hospital Clinic: Abercromby Street, St Joseph
Email [email protected]
Website www.TrinidadIVF.com
High blood pressure
Diabetes
Testicular lumps
Sexual problems
Chlamydia
Migraines
You were born with an abnormality
Thyroid disease
TEL: 868 622 8869, 868 622 6595
TEL: 662 8344, 222 8341
Facebook Trinidad IVF
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