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First Name

Last Name

Date of Birth

Age

Blood type

Hight (cm):

Body mass (kg):

Phone

Medical History

Do you smoke?

Yes

No

Do you consume alcohol regularly?

Yes

No

Do you have any allergies?

Yes

No

(If, yes, which ones)

Have you ever had any pelvic surgery or infertility surgery?

Yes

No

If yes, specify

Have you had any surgery in the abdominal area?

Yes

No

If yes, please provide detailed information about diagnosis and operation.

At what age did your period started?

When was your last period?

What is your interval between periods? [For example: 28 days]

Have you ever been pregnant?

Yes

No

If yes, please describe the outcomes and years (births/miscarriages/terminations).

How long you have been trying to get pregnant?

Have you undergone artificial IVF before?

Yes

No

If yes, how many times?

Did you use your own eggs?

Yes

No

If yes, how many eggs were retrieved?

Whether they were fertilized by IVF or via ICSI?

How many embryos were created as a result?

What was the quality of the embryos?

How many embryos were transferred?

If yes for how long? Describe the cause of the failure of the pregnancy?

Did you get pregnant from this IVF?

Yes

No

Have you ever had any tubal or ovarian infections?

Yes

No

Have you ever been diagnosed with a sexually transmitted disease?

Yes

No

xx. Have you ever had hepatitis?

Yes

No

Please indicate your infertility causes (if known)

xxii. Are there any hereditary disorders or fertility issues in your family?

Yes

No

Please list below any other information that could be pertinent to your treatment.

If you have any health problems that have not been addressed in this form, please upload it here.

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The information I have entered is truthful to the best of my knowledge.

At Med IVF, we understand the emotional and physical challenges that come with infertility. Our approach is designed to support you every step of the way, ensuring you receive the best care and guidance.

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Lefkosa/ Nicosia 99000, Cyprus.
info@med-ivf.com
+90 548 866 9092

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01954 717210

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