CD JSON Generator

FERTILITY HISTORY

Infertility

PrimarySecondary

Duration Of Marriage

Month(s)

Duration Of Infertility

Month(s)

Time Since Last Pregnancy (month)

Month(s)

Time Since Last Pregnancy (month)

Not applicable

Number And Outcome of Last Pregnancies

None

Union Method

Please Update Method

Postpartum / Post Abortal Complications

YesNo

CONTRACEPTIVE HISTORY

OTHER FACTORS WITH POSSIBLE EFFECTS ON FERTILITY

MENSTRUAL AND OVULATION HISTORY

PREVIOUS INVESTIGATIONS AND TREATMENTS FOR INFERTILITY

MEDICAL AND SURGICAL HISTORY WITH POSIBBLE ADVERSE EFFECTS ON FERTILITY

PHYSICAL EXAMINATION

PELVIC EXAMINATION

ULTRASONOGRAPHY OF PELVIS

HYSTEROSALPHINGOGRAM

LMP

Cycle Day

Date Of Hysterosalphingogram

Uterine Cavity

NormalAbnormal

Tubal Patency

PatentOccluded

LAPAROSCOPY AND DYE TEST

ADDITIONAL TEST

Other Test (Details)

SIGNATURES