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Online Consultation Dr Najeeb Layyous would be happy to provide a free online
consultation to your problem. He'll do his best to answer all queries. Please email your details in the following format , so that he can guide you more effectively. The better the question you ask, the better his answer will be ! Copy and paste the form, fill in the details, and them email it to Date__________________ Name _____________________________________Occupation____________ Partner Name_______________________________ Home Phone ____________________ Business phone ________________Fax No____________ Address ________________________________________________________ E-Mail _____________________________________________ City _______________________ State _________________ Postal Code _________________ GENERAL 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 a Reproductive Endocrinology and 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_____ Birth date ________ Height_________ Weight_________ Blood group ______________________Allergies to medicines _________ Menstrual periods occur every ________ days. Are they regular? __________Amount of bleeding ____ For how many days do you bleed? _________ Do you have endometriosis? ______ Do you have any medical problems? ______ If yes, please give details, including any medications _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ 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 _______ Number of abortions __________ Number of tubal pregnancies ________ Number of live births _________ TREATMENT HISTORY Have you had:
OTHER What else should we know about your case? Are there other pertinent test results, procedures or problems that have been identified? Give details of IVF results, if applicable: -Stimulation Protocol _______________________________________ -No. of follicles ___________________________________________ -No. of eggs _____________________________________________ -No. of embryos transferred _________________________________ -No. of frozen embryos ____________________________________ -Out come ______________________________________________ MALE HISTORY Age______________ Birth date ________________ Height ____________ Weight ________ Occupation ___________________ Allergies to medicines ______________ Blood group___ - Prior marriage __________________________________________________ - Number of pregnancies with a previous partner _________________________ - Do you have problems with evection or ejaculation ?_____________________ ______________________________________________________________ - Male medical problem ___________________________________________ - Current medications _____________________________________________ - Hormonal blood test _____________________________________________ - Previous surgeries _______________________________________________ - Family history of infertility _________________________________________ - Previous treatment for infertility _____________________________________ - Semen analysis : Volume ________________ PH _______________Date of test_____________ Liquefaction ________________ Count _____________________ Motility ________________ Type 1 ____________ Type 2 ___________ Type 3 ___________ Type 4 ___________ Normal forms __________________ WBCs _________________________ RBCs _________________________ If you had Azoospermia : Have you ever had testicular biopsy ? _________________________________ Date __________________________ Result ________________________________________________________ _____________________________________________________________ Ask specific questions that you would like addressed. _____________________________________________________________ _____________________________________________________________ E- mail or Fax us this form along with copies of your relevant medical records Dr. Layyous will then review the material and make a written report (including recommendations). Alternatively, he will speak with you on the phone regarding your case - if you prefer. Privacy Statement | Website Disclaimer and Legal Notice Location of clinic | Available treatments | Contact us | Site Index | Home page All
data at this web site are copyright (c) last modified 10/02/07 |