Physician name
Licence number


Patients name and age.


Medical history

Chronic disease and conditions

Chronic medications

Known allergies

Carried out surgical procedures

Laboratory and instrumental diagnostic tests

Hysteroscopy date

Cervical canal:

Uterine cavity:

Vaginal or cervical pathology or abnormalities compromising embryo transfer

TVS date and day of natural or HR cycle

Uterine shape Specify if abnormal

Uterine size Specify if abnormal (xx MM )

Uterine position:

Sharply deviated or anteverted/retroverted with probability to compromise embryotransfer

Submucose myomas:

Intramural myomas:

Subserouse myomas:


Endomerial regularity and lining (full layer thickness mm) in the mid-luteal phase of natural or hormonal replacement cycles.

RT Ovary:

Lt Ovary:

Hydrosaplinx ()

TVS additional remarks:

*Please provide the patient with ultrasound picture, including uterine sagittal view.

PAPs results (within 1-2 years) Date

Endometrial scratching or biopsy date and results (if applicable)

Mammography and Breast US if indicated (within 1 year)


Breast examination performed by Surgeon


ECG (within last 6 months)

Blood group and RH:

Blood tests dates (within last 3 months). Indicate if abnormal.
Blood chemistry including fasting glucose level. Date

Complete blood count (CBC) Date

Hemostasis PT, PTT Date

Urine test (culture and general) Date

Thyroid function (TSH, Free FT 4) Date

TORCH infections Date

Toxoplasmosis: Date

Rubella: Date

Cytomegalovirus: Date

Genital Herpes type one: Date

Genital Herpes type two: Date

STD ( Syphilis Ab, HBS Ag, HCV Ab, HIV) Date

Syphilis: Date

HBS Ag: Date

HCV Ab: Date

If Positive specify HCV Ag:

Chlamidia, Micoplasma, Thichomonas, Gonorrhea (cervical or urine PCR)

Partner / Spouse work up (if applicable)

Name Age

STD tests within last 3 monthes
(Syphilis Ab, HBS Ag, HCV Ab, HIV) Date

Chlamidia, Micoplasma, Thichomonas, Gonorrhea (urine PCR) Date

Spermogram (within last six monthes) Date

Patient follow up and endometrial preparation for embryo transfer

Additional information and remarks