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Medical Assessment Form
First Name
E-Mail
Address
Country Code
Phone Number
Date of Birth
Blood Type (if known)
Select Your Blood Type
A+
A-
B+
B-
AB+
AB-
O+
O-
I don't know
Weight (kg)
Select your weight
40kg
41kg
42kg
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126kg
127kg
128kg
129kg
130kg
Height (cm)
Select your height
145cm
146cm
147cm
148cm
149cm
150cm
151cm
152cm
153cm
154cm
155cm
156cm
157cm
158cm
159cm
160cm
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170cm
171cm
172cm
173cm
174cm
175cm
176cm
177cm
178cm
179cm
180cm
181cm
182cm
183cm
184cm
185cm
First Name
Relationship
Address
Country Code
Phone Number
Medical Conditions
Seizures
Hearth Disease
Diabetes
Lung
High Blood Pressure
Asthma
Stroke
Convulsions
Hepatitis
HIV / AIDS
Haemophilia
Cancer
Further Information (If neccessary)
Known Allergies
Medicine
Food
Plants
Insect Bites
Further Information (If neccessary)
Current Medication
Dose
Frequency
Further Information (If neccessary)
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 a general anaesthetic? If yes, did you experience any difficulties?
Do you have regular periods? How long is your normal cycle?
Please write the start date of your last three periods.
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)
Name
Address
Country Code
Phone Number
Blood Type (if known)
Select Your Blood Type
A+
A-
B+
B-
AB+
AB-
O+
O-
I don't know
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)
Sperm donor requirements (if applicable):
Egg donor requirements (if applicable):
About your desired IVF treatment in Cyprus
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)
When you are planning to travel to Cyprus for your treatment (approximate)
Any other relevant information:
(E.g. Flight details, number of people traveling, special dietary requirements, etc.)
Would you like to receive information and suggestions from Dream IVF regarding your visit to Cyprus?
Yes
No
Attach any extra medical files, test results, or patient forms you'd like to include with your assessment. Accepted formats: PDF, Word, images. Your input helps us deliver precise care. Thank you.
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