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Pacific in vitro fertilization institute

Pacific In Vitro Fertilization Institute
Patient Name: ____________________________

Height: ___________________________
Have you been treated for infertility before: ____No _____Yes Physician(s): ______________________ Date:____________ Physician:______________________ Date:____________ Physician: ______________________ Have you had surgery for varicocele repair? ___No ___Yes Date:____________ Physician: ______________________ Do you have any children conceived with another partner? Do you have or have you ever had: (check all that apply) ____ Blood Transfusion (date____/____/____) ____

What DRUGS have you taken for infertility? (Check all that apply)
Other – Specify ___________________________________ What TESTING have you done for infertility: (Check all that apply) ____ Testicular Physician: ___________________________________ Physician: ___________________________________ Physician: ___________________________________ What TREATMENTS have you had for infertility? (Check all that apply) ____ Artificial Date last cycle__________ Physician:___________________________ Date last cycle__________ Physician:___________________________ SEMEN ANALYSIS Date: ____/____/____ Lab:_____________ mil/ml_____ %mot______ Act______ Date: ____/____/____ Lab:_____________ mil/ml_____ %mot______ Act______ Pacific In Vitro Fertilization Institute
Patient Name: ____________________________
Do you have any medical problems?
Type:______________________________ Date:____/____/____ Treatment: Type:______________________________ Date:____/____/____ Treatment: Are you allergic to any MEDICATION? ____No ____Yes – list all and describe reaction Medication ______________________ Reaction: _______________________________________________ Medication ______________________ Reaction: _______________________________________________ Are you allergic to any FOODS? ____Yes – list all and describe reaction Food ____________________________ Reaction: _______________________________________________ Food ____________________________ Reaction: _______________________________________________ Are you taking any PRESCRIPTION MEDICATIONS? Prescription: _____________________ For: _____________________________________________________ Prescription: _____________________ For: _____________________________________________________ Are you taking any OVER-THE-COUNTER MEDICATION? ____No Medication: _____________________ For: _____________________________________________________ Medication: _____________________ For: _____________________________________________________ Do you take any HERBAL MEDICATINS/VITAMINS or health food supplements? Medication: _____________________ For: _____________________________________________________
Medication: _____________________ For: _____________________________________________________
List any members of your immediate family who have a history of infertility or breast cancer:
Relationship: _______________________ Condition:___________________ Treatment:__________________
How many caffeinated beverages (coffee, tea, soda) do you drink a day? _____________
How many/day:__________ How many years:_____________ started:_____________ Quitting? ______________ #Beer/week_____ #Wine per week_____ #Liquor/week_____ Do you use marijuana, cocaine or other simular drugs? ____No ____Yes - describe________________________________ Do you exercise?
PHYSICIAN NOTES:_________________________________________________________________________________

Source: http://www.pacificinvitro.com/pdf/MaleHistoryForm.pdf

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CSSL FACULTY BIOGRAPHY Da l ia h Sap e r Principal Daliah Saper is a member of the Illinois Bar and both the General Bar and Trial Bar of the U.S. District Court for the Northern District of Illinois. She has handledand is national tv, radio, and in several publications including: Fox News, CNBC, ABC News, The Chicago Tribune, WGN Radio, NPR, and a slew of smaller websites. She

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ARV treatment Fact Sheet 06 Side effects: Detailed information Bloating, wind and stomach pains Diarrhoea What is it? What is it? (wind) develops in the gut. This causes: move too quickly, resulting in diarrhoea Which ARVs can cause it? Which ARVs can cause it? taking a drug such as Nelfinavir. Some opportunistic infections or HIV itself can Stomach pai

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