PATIENT'S OBS/GYNAE HISTORY

What all are your complaints?* This field is required.CLICK NEXT AFTER TICKING YOUR OPTIONS

PCOS DIAGNOSED

PERIODS ARE NOT ON TIME

FAILED IVF OR IUI

LOW AMH

BLOCKED FALLOPIAN TUBE

ENDOMETRIOSIS

FIBROIDS

CAUSE UNKNOWN

Other

Name

First Name

Last Name

Date of Birth* This field is required.

Date

Marital Status* This field is required.

What's your Spouse's Date of birth

Date

Since how many years are you married ?

Is your Spouse/partner suffering with any illness/health concerns * This field is required.

Let us know in brief about your expectations with us regarding your health * This field is required.

Since how many years have you been trying to conceive ?

Have you ever been pregnant ?

YESNO

How many times have you been pregnant ?

Number of times your pregnancy reached at or above 7 months

Any history of Abortion / miscarriage ?

YESNO

If yes, then provide us details about it here -- Which month of pregnancy & Reason for the abortion

Any fetal abnormality detected during investigations ? like no heart beat, developmental disorder etc.

Is there a family history of infertility or genetic disorders?

YESNO

If yes , then let us know about it in brief

⁠Have you taken any medical treatment for infertility?

YESNO

What fertility treatments have you undergone ?* This field is required.

HORMONAL MEDICINES

IUI

IVF

AYURVEDIC

HOMEOPATHIC

Other

How many cycles of IVF have you undergone ?

What was the result of IVF cycles?

How many IUI cycles have you undergone?

What was the result of IUI cycles?

For How many months have you taken Hormonal medicines ?

What was the result of Hormonal medicines ?

For How many months have you taken Homoeopathic medicines ?

What was the result of Homoeopathic medicines ?

For How many months have you taken Ayurvedic medicines ?

What was the result of Ayurvedic medicines

If there is anything else about your Infertility journey then do let us know here !We want to understand and feel the journey you had so far for us to be your companion ahead !

How many times have you delivered ?

More than 3

Other

Was your 1st delivery ?

FULL TERM DELIVERY

EARLY DELIVERY

DELAYED DELIVERY

Other

How was the 1st delivery?

Normal delivery

Caesarian delivery

Forceps delivery

Vaccum delivery

Other

Was your 2nd delivery ?

FULL TERM DELIVERY

EARLY DELIVERY

DELAYED DELIVERY

Other

How was the 2nd delivery?

Normal delivery

Caesarian delivery

Forceps delivery

Vaccum delivery

Other

Was your 3rd delivery ?

FULL TERM DELIVERY

EARLY DELIVERY

DELAYED DELIVERY

Other

How was the 3rd delivery?

Normal delivery

Caesarian delivery

Forceps delivery

Vaccum delivery

Other

Provide us details about all your deliveries here

In case we have missed on asking you anything regarding the deliveries then do let us know here

When was your FIRST PERIODS / MENSES ?* This field is required.Let us know the age when you had your first Periods/Menses

When was The First day of your LAST PERIODS / MENSES ?* This field is required.

Date

Do you get your PERIODS on REGULAR INTERVAL ?* This field is required.

YESNO

In how many days does your periods repeat ?

If Irregular , then explain when did you had them last and details about the repetition of periods in last few months

For how many days does your periods last ?* This field is required.

1-2 days

3-4 days

5-7 days

more than 7 days

Intermittent ( Starts for few days then stop for few and then start again)

Do you have clots in your periods?* This field is required.

Yes

Have you ever taken any Hormonal medicines/OC Pills/ Contraceptive pills

Yes

How is your bleeding on 1st day?

TYPE 1

How is your bleeding on 2nd day?

How is your bleeding on 3rd day?

How is your bleeding on 4th day?

How is your bleeding on 5th day?

How is your bleeding on 6th day?

How is your bleeding on 7th day?

How is your bleeding on 8th day?

How is your bleeding on Last day?

What is the colour of your bleeding on 1st day?* This field is required.

ORANGE

PINK

BRIGHT RED

BROWNISH

MAROON

BLACK

GREEN

What is the colour of your bleeding on 2nd day?* This field is required.

ORANGE

PINK

BRIGHT RED

BROWNISH

MAROON

BLACK

GREEN

What is the colour of your bleeding on 3rd day?

ORANGE

PINK

BRIGHT RED

BROWNISH

MAROON

BLACK

GREEN

What is the colour of your bleeding on 4th day?

ORANGE

PINK

BRIGHT RED

BROWNISH

MAROON

BLACK

GREEN

What is the colour of your bleeding on 5th day?

ORANGE

PINK

BRIGHT RED

BROWNISH

MAROON

BLACK

GREEN

What is the colour of your bleeding on 6th day?

ORANGE

PINK

BRIGHT RED

BROWNISH

MAROON

BLACK

GREEN

What is the colour of your bleeding on 7th day?

ORANGE

PINK

BRIGHT RED

BROWNISH

MAROON

BLACK

GREEN

What is the colour of your bleeding on 8th day?

ORANGE

PINK

BRIGHT RED

BROWNISH

MAROON

BLACK

GREEN

What is the colour of your bleeding on Last day?* This field is required.

ORANGE

PINK

BRIGHT RED

BROWNISH

MAROON

BLACK

GREEN

What is the CHARACTER of your bleeding on 1st day?* This field is required.

Fluid containing Clots

Containing SHREDS / MENBRANES

THIN / WATERY

FULLY CLOTTED

THICK

LUMPY

What is the CHARACTER of your bleeding on 2nd day?* This field is required.

Fluid containing Clots

Containing SHREDS / MENBRANES

THIN / WATERY

FULLY CLOTTED

THICK

LUMPY

What is the CHARACTER of your bleeding on 3rd day?

Fluid containing Clots

Containing SHREDS / MENBRANES

THIN / WATERY

FULLY CLOTTED

THICK

LUMPY

What is the CHARACTER of your bleeding on 4th day?

Fluid containing Clots

Containing SHREDS / MENBRANES

THIN / WATERY

FULLY CLOTTED

THICK

LUMPY

What is the CHARACTER of your bleeding on 5th day?

Fluid containing Clots

Containing SHREDS / MENBRANES

THIN / WATERY

FULLY CLOTTED

THICK

LUMPY

What is the CHARACTER of your bleeding on 6th day?

Fluid containing Clots

Containing SHREDS / MENBRANES

THIN / WATERY

FULLY CLOTTED

THICK

LUMPY

What is the CHARACTER of your bleeding on 7th day?

Fluid containing Clots

Containing SHREDS / MENBRANES

THIN / WATERY

FULLY CLOTTED

THICK

LUMPY

What is the CHARACTER of your bleeding on 8th day?

Fluid containing Clots

Containing SHREDS / MENBRANES

THIN / WATERY

FULLY CLOTTED

THICK

LUMPY

What is the CHARACTER of your bleeding on Last day?* This field is required.

Fluid containing Clots

Containing SHREDS / MENBRANES

THIN / WATERY

FULLY CLOTTED

THICK

LUMPY

Does your Bleeding during Menses cause Burning?* This field is required.

YESNO

Do you feel that your Bleeding during menses is having FOUL SMELL ?* This field is required.

YESNO

In case, We missed anything related to your MENSES ( PERIODS), you can let us know about it here in your words!* This field is required.

Do you have any white discharge/vaginal discharge?* This field is required.

YESNO

Since how long are you having vaginal discharge ?

How do you feel when there is a Vaginal discharge?

BURNING in & around Vagina

ITCHING in & around Vagina

NO SENSATION

Other

When do you experience your VAGINAL DISCHARGE being increased?

Morning

Afternoon

Evening

Night

When do you experience your VAGINAL DISCHARGE being increased?

After exercise / after motion

After pain in abdomen

During stool

During urination

After urination

After walking

When do you experience your VAGINAL DISCHARGE being increased in relation to Menses ?

Before menses

In between menses

After menses

2 weeks after menses

What is the type of/ texture of your VAGINAL DISCHARGE?

Albuminous / like white of the egg

BLOODY

CREAMY

JELLY LIKE

MILKY

STRINGY/ROPY

WATERY

THICK

LUMPY

Do you experience constipation while having VAGINAL DISCHARGE ?

YESNO

Do you experience any pain in abdomen while having Vaginal discharge ?

YES

What is the colour of your vaginal discharge ?

YELLOW

GREEN

WHITE

BROWN

RED

SKIN COLOURED

BLACK

TRANSPARENT LIKE WATER

Do you get stain on your under garment when you are having VAGINAL DISCHARGE ?

YESNO

Is it difficult to wash off the stain on your under garment?

YESNO

What colour of stain do you get on the inner side of the undergarment while having VAGINAL DISCHARGE?(This staining is mostly observed after washing the UNDERGARMENT)

BROWN

YELLOW

GREEN

GRAY

COLOUR OF YOUR GARMENT FADES AWAY

Do you notice any offensive/foul smell in your VAGINAL DISCHARGE?

YESNO

How do you feel is the flow in the terms of quantity of your VAGINAL DISCHARGE ?

Profuse/ Heavy / Excess in quantity

Scanty / Low in quantity

Does your VAGINAL DISCHARGE causes STIFFENING/ HARDENING of the UNDERGARMENT ?

YESNO

Do you experience any of the following during VAGINAL DISCHARGE

Pain in lower back

Weakness

Anemia

Headache

VAGINAL DISCHARGE instead of menses

Palpitation

Pain in vagina

Swelling of vagina

Pain in urination

In case We missed anything related to your VAGINAL DISCHARGE, you can let us know about it here in your words!

PATIENT'S OBS/GYNAE HISTORY - KJ