Fertility Free Qoutes by kaguya August 13, 2019 Step 1 of 6 0% You entered this page, meaning you need help with infertility treatment for sure. As you know, infertility treatment steps, tests and examinations are numerous and complicated. Therefore, if you want to make sure that your treatment trip in Iran, will work out for you, please fill out the following form carefully and thoroughly. Make sure to answer the questions in detail please.PhoneEmail Male ProfileName First Last Date Of Birth Date Format: MM slash DD slash YYYY Female ProfileName: First Last Date Of Birth Date Format: MM slash DD slash YYYY Conjugal IssuesWhat is your reason for visiting? please explain.How long have you been married?Do you have any family relationship with your spouse?yesNoWhat is your relationship with your spouse?Is there any previous history of special disease in your family or your spous’s? (Father, mother, sister and brother)yesNoPlease Explain.Do you have any genetic disorders in your family?yesNoPlease Explain: Female IssuesDo you have any special disease currently?ِYesNoWhat disease do you have now? Including its onset date.Menstrual cycle patternRegularIrregularExplain Menstural cycle pattern irrigularityHow many days of bleeding do you have?Please enter a number greater than or equal to 0.Do you have severe cramping or pelvic pain with your periods?Age when you had your first period in your life?Please enter a number greater than or equal to 0.Date of the 1st day of your last menstrual period Date Format: MM slash DD slash YYYY Which of these diseases are you suffering from? chlamydia gonnorhea siphilis hepatitis Hiv / Aids genital warts /hpv Complete explanation of the disease including the disease onset dateHave you had any surgeries?YesNoIf you had any surgeries write the reason, type and year of the surgeryWhen was your last pap smear? Date Format: MM slash DD slash YYYY Have you ever had a mammogram?YesNoDate of mammogram? Date Format: MM slash DD slash YYYY When was your last breast ultrasound? Date Format: MM slash DD slash YYYY Have you ever done hysterosalpingography? Date Format: MM slash DD slash YYYY Are you allergic to any kinds of medication or foods?YesNoList and describe reactions:List of medicines you currently takeUpload the woman’s medical document here please. Man IssuesDo you have any special disease currently?ِYesNoWhat diseases do you have now? Including its Onset dateList of medicines you currently takeWhich of these diseases are you suffering from? chlamydia gonnorhea siphilis hepatitis Hiv / Aids genital warts /hpv Complete explanation of the disease and the disease onset dateUpload the man’s medical document here please. Sexual relation issuesWhat is your contraceptive method?How many times do you have intercourse per week?Please enter a number greater than or equal to 0.Do you feel pain during the intercourse?yesNoIf you have pain with intercourse explaine:Have you had any sexually transmitted diseases?YesNoPlease Explain PregnancyTotal number of pregnanciesPlease enter a number greater than or equal to 0.NVD. Or CS.?Did you use iui /ifv /icsi to get pregnant?Have you had any problems with your previous pregnancies?Number of ectopic pregnancies (date):Number of misscariage (Less than 20 weeks) date:Number of elective termination (abortion):If you had curettage or used Misoprostol/Cytotec please write it down.Number of premature deliveries ( less than 37 weeks)Which of the following items has happened for you? Fullterm Delivery Delivering a live baby Delivering a stillborn baby Please explainNumber of your alive childrenUpload other medical document here please. Δ This iframe contains the logic required to handle Ajax powered Gravity Forms. Share FacebookTwitterWhatsappTelegramEmail
