Identification of a couple

Identification of a couple
Woman’s name
Woman’s surname
Date of Birth
Man’s name
Man’s surname
Date of Birth
Adress:

E-mail 1:
E-mail 2:
tel. No. 1:
tel. No. 2:
Please tick the appropriate answer and mention who suffers Family anamnesis
Malignancy YES NO breast uterus ovary other Others Please tick the appropriate answer and specify the details Personal anamnesis
Malignancy YES NO breast uterus ovary other Other informations
Do you have an allergy? YES NO What are you allergic to? Do you smoke? YES NO Cigerettes per day: Do you use any medications YES NO What medication do you use? If yes, please specify Blood group:
Findings should be later documented
Gynaecological anamnesis
Specify the shortest and the longest period from the first day of your bleeding until the beginning of next bleeding and the shortest and the longest period of your menses At what age did your menses begin? . years Gynaecological diseases
Please tick the appropriate answer and specify if necessary YES NO Cysts YES NO Brest disease YES NO Gynaecological operation
Completion:

Man
Family anamnesis
Please tick the appropriate answer and mention who suffers from disease, specify the details Personal anamnesis
Please tick the appropriate answer and specify the details YES NO Hepatitis YES NO A B C other Trombosis YES NO Other informations
Do you have an allergy? YES NO What are you allergic to? Do you smoke? YES NO Cigerettes per day: What medication do you use? If yes, please specify Blood group:
Findings should be later documented
INFERTILITY
Please tick what part was examined and specify if necessary by using different method YES NO Evidence of ovulation US foliculometry YES NO Evidence of ovulation by using EXECUTED TESTS FSH between the 2nd and the 5th day YES NO Value: of a cycle LH between the 2nd and the 5th day YES NO Value: of a cycle TSH YES NO Value: Prolactin YES NO Value: Progesteron YES NO Value: Others: if possible anti HbC IgM Value: hepatitis C anti HCV antibodies Value: Spermanalysis Please tick the appropriate answer In year: Findings: Normal Minor pathological Pathological Major pathological Azoospermia In year: Findings: Normal Minor pathological Pathological Major pathological Azoospermia In year: Findings: Normal Minor pathological Pathological Major pathological Azoospermia azospermie In year: Findings: Normal Minor pathological Pathological Major pathological Azoospermia Actual history of infertility treatment
stimulation YES NO Intrauterine insemination (IUI) with ovarian stimulation times? - Clomid YES NO Intrauterine insemination (IUI) with ovarian stimulation times? - gonadotropins YES NO IVF cyclus YES NO In year

Completion:

Source: http://gest.cz/en/doc/GEST-questionnaire-3-2011.pdf