Dr Rajeev Agarwal | Second Opinion Form

Wife Name

Husband Name

Email Address

Address

City Of Residence

Country

Pin Code

Mobile No

Married Since

Contraceptive Usage Yes No

Condom Oral Pills Copper T

If Yes, for how long

How long have you been trying to get pregnant?

How long have you been trying to get pregnant with doctor's consultation?

Doctor Category :

General Gynecologist Infertility Specialist

Reason for Infertility (Why do you think you are not getting pregnant?

Male Factor Infertility
Azoospermia
Tubal Factors
Low Sperm Count
Endometriosis
Poor Ovarian Reserve
PCOS
Unexplained Infertility
Don't Know

Age

Date of birth

Height(ft & in)

Feet

Inch

Weight(kg)

Menstrual periods occur every:

For how many days do you bleed?

Do you bleed heavy?

Yes No

Do you have very painful periods?

Yes No

Have you ever had Tuberculosis?

Yes No

Sl No	Year	Mode of Conception	Fate	Remarks

No of times performed:

Type of Stimulation:

Number of attempts

Sl No	Year	Location	Doctor	Stimulation Drugs	No Of Oocytes Recovered	No Of Embryo	Stages

Any Special Remarks:

Embryo Transfer History

Sl No	Year	Location	Doctor	Fresh (Number and Grade)	Frozen (Number and Grade)	Assisted Hatching (Yes / No)
						Yes No
						Yes No
						Yes No

Has heparin been used?

Yes No

Has assisted Hatching been done?

Yes No

Has Endometrial Scratching been done?

Yes No

Has Intralipids been used?

Yes No

Has Steroids been used?

Yes No

Has Ecosprin been used?

Yes No

Medical problems and current medications of Female Partner

Recent Reports (Fill only the ones relevant to you)

Test	Date (MM/YY)	Value
HB
HPLC
PPBS
HBSAG
TSH
PRL
D-TOTAL CA125
ANTI THYROGLUBIN ANTIBODY
LUPUS
Anti-Cardiolipin Antibody
Anti-Phospholipid Antibody
KARYOTYPING
AMH (Anti Mullerian Hormone)
If you have any other relevant reports, please send as an attachment.		Yes No

Please click a picture or scan and attach reports of the following investigations (if relevant in your case). For Hysteroscopy and Laparoscopy kindly attach the videos for the same as well:

TVS or Trans Vaginal Sonography :

Yes No

SIS or Saline Infusion Sonohysterography

Yes No

HyCoSy/Hystero Salpingo Contrast Sonography

Yes No

HSG or Hysterosalpingography

Yes No

Hysteroscopy

Yes No

Laparoscopy

Yes No

Age

Weight

Date of birth:

No. of Pregnancies with previous partner:

Do you have problems with erection or ejaculation? Yes No

Semen Analysis Report

Date
Enter Date
Sperm Count
Motility
Morphology

DNA Fragmentation Index Report Yes No

Any other relevant history or Investigation Yes No

Second Opinion Form