Have you had any tests done before? If yes:Woman:HSG, HormonesUltrasonographyHysteroscopy
Man:SpermogramHormoneTestis Doppler
Woman’s age
Man’s age
Menstruation regularity
Any previous operations?
Any chronic diseases? If yes, please provide details.
At how many weeks did you miscarriage?First miscarriageSecond miscarriageThird miscarriage
Any diagnosis for the etiology? (Do you know the cause of the miscarriage?)
Regular intercourse (/week)?
Is this your first marriage?YesNo
If no, have either of you had a pregnancy before?YesNo
Note: Our fertility department will be in contact with you soon to arrange your appointment.
Date of your last menstrual period:
Your Last Cycle At:
Your baby will come on approximately:
