IVF Consultation Form

IVF Pre-Consultation Form

Please complete this form before your appointment. Your information will be sent securely to the clinic team.

1) Personal & Contact Details

Full name *

Email *

Phone number

Age *

Height (cm)

Weight (kg)

Marital status

Previous fertility clinic? (If yes, where)

2) Menstrual History

Age at first period (menarche)

Are your cycles regular?

Average cycle length (days)

Duration of bleeding (days)

Painful periods (dysmenorrhoea)?

First day of last menstrual period (LMP)

3) Pregnancy History

Have you ever been pregnant before?

If yes, how many times?

Please list outcomes (live birth, miscarriage, ectopic pregnancy, termination) and dates if known

If live birth: delivery type

Any pregnancy/delivery complications?

4) Fertility History

How long have you been trying to conceive? (months/years)

Previous fertility treatment?

If yes, please specify (OI/IUI/IVF/ICSI), number of cycles, eggs collected, embryos created, transfers, pregnancy outcomes

5) Gynaecological & Surgical History

Any gynaecological surgery? (e.g. fibroids, cysts, laparoscopy, caesarean)

Diagnosed with endometriosis?

Known uterine conditions (fibroids, polyps, adenomyosis)?

Cervical smear test: date/result (if known)

6) Medical & Hormonal History

Medical conditions (thyroid, diabetes, hypertension, autoimmune disease, etc.)

Any known blood clotting disorders?

Any allergies?

Current medications/supplements

7) Investigations & Results (if available)

AMH (date/result)

FSH/LH/Oestradiol (date/results)

Pelvic ultrasound findings

HSG / HyCoSy (tubal patency) result

Genetic tests (if applicable)

Please bring copies of any lab reports and imaging results to your consultation.

8) Lifestyle Factors

Smoking

If current smoker: cigarettes per day

Alcohol (units per week)

Caffeine (cups of tea/coffee per day)

Exercise (briefly)

High stress or night shifts?

9) Partner Information (Brief)

Partner’s age

Has a semen analysis been done?

Known male factor fertility issues?

10) Expectations & Concerns

What are your expectations from IVF treatment?

Any previous negative/difficult fertility experiences?

Questions you would like to discuss with the doctor