Medical Case Intake Form

Please complete all the required fields accurately

Personal Details

Full Name

Age

Occupation

Obstetric & Delivery History

Last Child Gender

Last Child Age

Newborn Health Status

History Of Pregnancy

Number Of Pregnancies

History of Miscarriage

Yes No

Before 20 Weeks

After 20 Weeks

Ectopic Pregnancy

Yes No

Premature Birth History

Delivery Method

C-Section Delivery

Normal Vaginal Delivery (NVD)

Medical & Gynecological Conditions

Surgical & Lab History

Paraclinical Laboratory Tests

Hysterosalpingography (HSG) Report

Laparoscopy Details

Surgeon / Physician Name

Laparoscopy Pathology Result

Hysteroscopy Details

Surgeon / Physician Name

Hysteroscopy Pathology Result

ART History (IUI, IVF, ICSI)

Treatment Center Name

History of Drug / Tobacco Use

Cigarettes

Hubble-Bubble (Hookah)

Other Substances

Partner / Husband s Information

Husbands Age

Husbands Occupation

Varicocelectomy History

Sperm Processing & Analysis Result

Attach Medical Documents

Upload Lab Results, Scans, or HSG Reports

Accepted formats: JPG, PNG, PDF (Multiple files allowed)

Initial consultation and admission