Dr Malpani would be happy to provide a second opinion on your problem. Please fill in the following form, and email it to malpani@vsnl.com , or courier it (with a self-addressed stamped envelope enclosed with it), to:

Dr Malpani
Malpani Infertility Clinic
Jamuna Sagar
SBS Road
Colaba
Bombay 400 005
India.
Tel: 91-22- 215 1065, 215 1066, 218 3270
FAX: 91-22-215 0223

Date __________________

Name of wife ______________________________________

Name of husband __________________________________

SOCIAL HISTORY

How long have you been married? _________________

How long have you been trying to get pregnant? __________________

How long have you been trying to get pregnant with a doctor's help? ____________________

Was it a General Gynecologist or an Infertility Specialist? _________

About how many times a month do you have intercourse? _________

Does either partner smoke? _______ How much? _______________________

Does either partner use recreational drugs? _______ Which ones? _____________________________

____________________________________________________________________________________

FEMALE HISTORY

Age _____ Birthdate __________________ Height ___________ Weight ___________

Menstrual periods occur every ________ days. Are they regular? __________

For how many days do you bleed? _________ Do you have endometriosis? __________

Have you ever had pelvic inflammatory disease (PID)? _______

What pelvic surgeries have you had? _____________________________________________________

What were the findings? ________________________________________________________________

____________________________________________________________________________________

Number of pregnancies with this partner _______

Number of pregnancies with a previous partner _______

Number of miscarriages (abortions) _______

Number of tubal pregnancies ________

Number of live births _________

Medical problems and current medications of female partner: __________________________________

____________________________________________________________________________________

MALE HISTORY

Age _____ Birthdate __________________

Number of pregnancies with a previous partner _______

Do you have problems with erection or ejaculation? _______

Sperm count: ____________ million per ml.

Motility ___________ %

Male medical problems and current medications ____________________________________________

____________________________________________________________________________________

MEDICAL HISTORY
Have you had: Test Yes/No Date Result
Hysterosalpingogram
Laparoscopy
Hysteroscopy
Other

Treatment Yes/No How many Date Any success?
Ultrasound monitoring
Clomiphene stimulation with intercourse
Clomiphene stimulation with Insemination (IUI)
Injectable HMG stimulation with intercourse
Inseminations (IUI) without any stimulation
Injectable HMG stimulation with insemination (IUI)
In vitro fertilization (IVF)
ICSI

Give details of IVF / ICSI results, if applicable. Stimulation protocol used Follicles grown Embryos formed Embryos transferred Embryos frozen


OTHER
Are there other pertinent test results, procedures or problems that have been identified?

____________________________________________________________________________________

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Credits: Dr. Aniruddha Malpani, MD and Dr. Anjali Malpani,