IVF Consultation Form

👤 Personal Information

🏥 Medical History

Known Medical Issues (select if applicable):
SeizuresHeart DiseaseDiabetesLung ProblemsHigh Blood PressureAsthmaStrokeCancerNone

🌿 Allergies

Known Allergies (select if applicable):
FoodPlantsMedicationInsect StingsOtherNone

💨 Lifestyle Habits

Do you smoke?NoYes (1-10 per day)Yes (10+ per day)

👩‍⚕️ Reproductive History

Are your menstrual periods regular?YesNo

🔬 Gynecological History

Gynecological Issues (select if applicable):
FibroidEndometriozisOvarian CystsAbnormal Cervical CytologyNone

🧪 Fertility Tests and IVF

👨 Partner Information and Planned Treatment

Privacy Policy I have read and agree.