Your Name*

Age *

Weight and Height? *

Blood Group *

Is the menstrual cycle regular? How many days does the bleeding last?*

Does you feel pain during intercourse?*

How many years have you been married?*

How long have you been trying to get pregnant?*

Have you ever done IVF or IUI? How many times? When? Please write carfully.*

How many times did you have cesarean section? *

Have you ever done hysterosalpingography (HSG)? Please send report.*

Have you ever done Pap smear? Please send report *

How many times did you get pregnant? *

Have you ever had an miscarriage? In which week of pregnancy was it? why? Please write carefully*

Are there any genetic diseases in the your family? *

Have you ever had surgery? what was that? How many times? *

Do you have one of the common diseases? like Diabetes - Hypertension - Thyroid disorder *

Are you currently taking a particular medicine?*

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