Medical Assessment Form

Patient Details

First Name *

E-Mail *

Address

Country Code *

Phone Number *

Date of Birth

Blood Type (if known)

Weight (kg)

Height (cm)

Emergency Contact

Emergency Contact Name

Relationship

Emergency Contact Address

Emergency Contact Country Code

Emergency Contact Phone Number

Medical History

Medical Conditions — Further Information (If necessary)

Do you or any of your family members carry or have a known genetic condition? If yes, please provide details.

Known Allergies

Medicine Food Plants Insect Bites

Allergies — Further Information (If necessary)

Current medications (name, dose, frequency)

Medications — Further Information (If necessary)

Do you smoke? If yes how many per day?

Do you have any medical related illnesses, disabilities or infirmities that have required the regular care of a physician over the past 12 months? Please describe in general terms.

What illnesses/medical conditions have you had in the past 5 years?

Have you been hospitalised in the last 5 years? If so for what reason?

Have you ever had any surgeries? If so, please provide details.

Have you ever had a general anaesthetic? If yes, did you experience any difficulties?

Fertility & Gynecological History

Do you have regular periods? How long is your normal cycle?

Your last period date

Your previous period date

Your period date before that

How long have you been trying to conceive?

Have you ever used any kind of contraception? If yes, when did you use it and how long did you use it for?

Have you ever had any gynecological problems such as fibroids, endometriosis, ovarian cyst, abnormal cervical cytology? Please describe in detail.

Have you ever had any gynecological surgery?

Please write your current cycle day 3 FSH, LH, Estradiol, Prolactin and TSH levels (if known).

Have you ever undergone any assisted reproductive technique to get pregnant? (e.g. intrauterine insemination, in vitro fertilization) Please write in detail: the number of eggs retrieved / the number of embryos transferred / the result of treatment / the names of the medications and their daily dosages used during these IVF cycle(s) / your FSH, LH, Prolactin, TSH, Estradiol levels during the course of these IVF cycle(s).

Partner Details

Partner Name

Partner Address

Partner Country Code

Partner Phone Number

Partner Blood Type (if known)

Sperm features (if known): spermiogram date, count, motility, morphology.

Other details regarding the partner's medical situation: e.g. does he have any children? Has he had any surgical intervention on his reproductive system? (e.g. vasectomy)

Donor

Sperm donor

Egg donor

Your Treatment

IVF treatment(s) you are seeking (e.g. IVF, egg donation, PGS, sperm donation, etc.) Please specify if unsure / need more medical guidance.

Your period start date (estimate)

Which month are you planning on travelling to Cyprus for your treatment?

Do you plan to stay in Cyprus for the entire duration of your treatment?

Yes - I intend to be in Cyprus for approximately 18 days, starting on day 2 or 3 of my menstrual cycle. No - I will undergo stimulation at home and plan to stay in Cyprus for about 11 days for the remaining IVF procedures.

Any other relevant information (e.g. flight details, number of people traveling, special dietary requirements, etc.)

Contact Preferences

Would you like to receive information and suggestions from Dream IVF regarding your visit to Cyprus?

Yes No

What is your preferred contact method?

WhatsApp Email

What timezone are you located in?

Please indicate your availability for the consultation calls (days of the week)

Mondays Tuesdays Wednesdays Thursdays Fridays Saturdays (limited availability)

Please indicate your available timeslots (based on your local time zone)

Mornings Afternoons Evenings

Attach any extra medical files, test results, or patient forms you'd like to include with your assessment. Accepted formats: PDF, Word, images.

Up to 5 files (PDF, Word or images), max. 10 MB each, 50 MB in total.

Declarations

I hereby declare that I have provided a complete and accurate medical history, including all past and pre-existing conditions and medications, to the best of my knowledge, which may be relevant to my IVF treatment in Cyprus. I understand that this information will be transferred to the referred clinic(s) in order to seek medical guidance on treatment options.

I confirm that the data I have supplied is accurate to the best of my knowledge and that Dream IVF Cyprus cannot be held responsible for any consequences arising from inaccurate or incomplete information. For further details, please refer to our Privacy Policy.

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