Name Surname

How old are you and your partner? (Age of Woman)

How old are you and your partner? ( Age of Man)

Do you have any chronic diseases and any medications that you use regularly?

Do you have any previous pregnancy or children? Were they with treatment or spontaneous? Did you have any spontaneous abortions or pregnancy loss?

How long have you been trying to conceive?

How is your menstrual cycle? Is it regular or irregular?

If regular;

What’s the average cycle day (e.g.: once in every 28-30 days)

How long does your menstruation lasts? (e.g.: 4-5 days)

If irregular:

: Please define the irregularity (e.g.: once in 40-50 days or once in every 2-3 months or no menstruation without a medication…)

Did you have any previous treatment (In-Utero Insemination or IVF)? If yes, please indicate how many times and the results (how many oocytes, how many embryos, pregnancy results).

Plase indicate the results of the following tests if you previously had them done; (Antimullerian Hormone: - FSH: - Estradiol: - TSH: - Hysterosalpingography: - Semen Analysis:

Did you have any surgery before (e.g. ovarian cyst, curettage/abortion, myoma uteri…)

If you have any genetic tests, please indicate the results.

E-mail

Phone Number