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Location : 1 Springwood Ave, Narre Warren VIC 3805
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Fertility & IVF support Program Online Assessment
This assessment takes 8 mins to complete
Male
Female
Your current Weight(kg)?
When did you get married?
Do you take contraception: Method
Do you take contraception, How long?
History of remarriage?
Yes
No
Have you had abortion?
Yes
No
Have you had premature delivery?
Yes
No
Have you had stillbirth?
Yes
No
Whether there is any abnormality during and after delivery in those with a history of full-term delivery: Dystocia
Yes
No
Whether there is any abnormality during and after delivery in those with a history of full-term delivery: Postpartum hemorrhage
Yes
No
Whether there is any abnormality during and after delivery in those with a history of full-term delivery: Artificial placenta dissection
Yes
No
How many children do you have at present?
0
1
2
3
4
5
6
7
Menstruation: Age at menarche
Menstruation: cycle time
Menstruation: Blood amount
Normal
A Lot
A Little
Menstruation: Duration (days)
1
2
3
4
5
6
7
8
9
10
11
12
Menstruation: color
Dark Red
Bright Red
Pink
Dark Purple
Purple Black
Purple Red
Crimson
Menstruation: Texture
Think
Thick
Normal
Menstruation: blood clots
Yes
No
Signs of ovulation: secretions
Yes
No
Signs of ovulation: Menstrual abdominal pain
Yes
No
Signs of ovulation: Vaginal bleeding
Yes
No
Leucorrhea amount:
A Lot
A Little
Leucorrhea colour:
White
Yellow
Do you suffer from morning sickness?
Yes
No
Development since puberty sexual organ development: Breast
Normal
Abnormal
Whether the genitals are fat
Yes
No
Development since puberty: hairy
Yes
No
Development since puberty: endocrine disorder
Yes
No
Have you ever had following disease?
Mumps
Measles
Scarlet Fever
Tuberculosis
Schistosoma
Chronic Wasting Disease
Endocrine And Metabolic Diseases
Malnutrition
Vaginitis
Pelvic Inflammatory Disease
History of other reproductive system diseases
History of lower-abdominal surgery:
Ectopic Pregnancy And Its Accessory Surgery
Intrauterine Operation History Such As Abortion
Appendicitis
Intestinal Obstruction
When did you have the surgery
Where did you have the surgery?
Whether there are abnormalities before and after surgery?
Yes
No
When did you start treatment after finding infertility?
What examinations and/or treatment have you taken?
What is the outcome？
About Family history, Genetic disease
Yes
No
About Family history: History of venereal disease
About Family history: Are the pregnancy and reproductive history of parents and siblings normal?
Yes
No
About Family history: Have you ever taken genetic test?
Yes
No
About Sex status: Sexual knowledge
Yes
No
About Sex status: Sexual disorder
Yes
No
About Sex status: Intercourse frequency per month
About Sex status: Duration of minutes
About Sex status: Whether you are in ovulation period?
Yes
No
Not Sure
About Occupation and hobbies: What do you do?
About Occupation and hobbies: If you are doing physic job, what is the labor intensity?
Intesive
Weak
Normal
About Occupation and hobbies: Do you long time stand or in a forced position?
Yes
No
About Occupation and hobbies: Have you ever exposed to radiation or chemical poisons?
Yes
No
About Occupation and hobbies: What are they if you ever exposed to radiation or chemical poisons?
Yes
No
About Occupation and hobbies: Whether there are alcoholics in the family?
Yes
No
Do you have anything else want to tell us?
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