Questionnaire
Dear Sir/Mam,
It is our pleasure to offer you a free online consultation and second opinion. This service is to provide you with our help and support without any liabilities and full assurance of confidentiality. You will get a reply in 24 hours.
All you need to do is fill in the basic medical information to get an insight into your situation. Not all fields are compulsory and you are free to leave them blank. However, the more the details you provide, the better our advise will be!

Why should you do this?
1.Our opinion will help you make sure you are on the right track.
2.Team Aster IVF can provide you with additional options your doctor may not have discussed with you.
3.You can increase your chances of creating your own IVF success story, like so many of our patients have done here.
4.This form can help you become better organized, and a well-informed patient gets better medical care!

Please don't feel embarrassed or hesitant ! We hope to be your partners in your journey towards a hopeful tomorrow.

Names of both partners
Your answer
Age of both partners:
Your answer
Where did you hear about us ?
Trying to conceive since
Your answer
Type of Infertility
Address:-
Your answer
Telephone number
Your answer
Mobile no.
Your answer
Skype ID
Your answer
Email
Your answer
Referred by
Your answer
Cause of infertility
Your answer
History of both the patients
Past History (medical/surgical):
Partner
1) Hypertension, Diabetes, cancers, asthma, Kochs, DVT , Heart disease, Hypothyroidism. (Or any other- Specify):
Your answer
- H/0 Surgeries
Your answer
2) Drug Allergies
Your answer
3) History of long-term medications
Your answer
4) Addictions if any:
Your answer
Menstrual History:
1) Last menstrual period
MM
/
DD
/
YYYY
2) Past menstrual cycles
3) Number of days of period and after how many days
Your answer
4) History of past pregnancies (if any)
Your answer
5) Any miscarriages in past:
Your answer
6) Number of children with previous partners
Treatment History:
1) Number of cycles of Ovulation Induction and name of the drug:
Your answer
2) Number of cycles of Intrauterine Insemination (IUI) :
Your answer
3) Number of cycles of IVF
Your answer
4) Number of cycles of ICSI:
Your answer
5) Any other fertility treatment :-
Your answer
Investigations:
(Please send scanned copies of actual reports by emailing us at info@asterivf.com)
Male Partner
1) Blood group
Your answer
2) HIV
Your answer
3) VDRL
Your answer
4) HCV
Your answer
5) HBsAg
Your answer
6) Semen Culture
Your answer
7) Sperm Count
Your answer
8) Motile sperms (%)
Your answer
9) Morphology
Your answer
Female partner
1) Blood group
Your answer
2) Urine routine
Your answer
3) Fasting blood sugar
Your answer
4) Post-lunch sugar
Your answer
5) Lupus antigen/ Ab
Your answer
6) HIV
Your answer
7) HBsAg
Your answer
8) VDRL
Your answer
9) HCV
Your answer
10) FSH
Your answer
11) LH
Your answer
12) Prolactin
Your answer
13) TSH
Your answer
14) Lupus antigen/ Ab
Your answer
15) Hystero-Laparoscopy, Findings:
Your answer
Other investigations (if any, please specify):
Your answer
You can also email us at info@asterivf.com
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