Rotunda IVF New Patient Appointment Form

Please complete the following form including the medical history section. Upon receipt of this form you will be contacted to schedule an appointment.

Privacy Policy

I have read and understood the Rotunda IVF Privacy Policy and I agree to the processing of my personal data as per this policy. I am aware that I can contact dpo@virtushealth.ie if I have any queries regarding the processing of my personal data or if I wish to withdraw consent for this processing.

I agree to the Rotunda IVF Privacy Policy

General Information

First name

Surname

Maiden name (if applicable)

Gender

Date of Birth

Full postal address

Personal email address

Home telephone number

Ok to leave a message?

Work telephone

Ok to leave a message?

Mobile phone

Ok to leave a message?

General information cont.

Nationality

Occupation

PPS Number

DPS number

Known allergies

GP name

GP Address

Do you have health insurance?

Do you have a medical referral to RotundaIVF?

Name of referring doctor

If you were not referred by a doctor please indicate how you heard about RotundaIVF?

Female Patient Medical History

Please complete this form to the best of your knowledge. If there are any question you are uncertain about, do not worry. The details will be discussed with the doctor at the first appointment.

The form will take some time to complete. if you have any questions or queries, please do not hesitate to contact us.

If you have further information, medical records or otherwise, please bring them to the first appointment so that your doctor can review them.

Height

Weight

Have you ever undergone an operation? (If so, please give details of all operations including the year).

Operations

Are you currently on any medications?

How long have you been trying to conceive?

Have you used contraception before?

Are you currently attending a medical doctor or being treated for an illness or medical condition?

Have you had any illness or been treated for a medical condition in the past?

Do you have any general medical complaints at present?

Are you currently using any non fertility medication?

Social History

If you smoke, how many cigarettes do you smoke per day?

If you are no longer a smoker, when did you give up smoking?

If you drink alcohol how many units do you consume per week?

Do you or have you taken any form of recreational drugs?

Where have you recently travelled to? (last six months)

Have you every travelled to or into an area known to be high medical risk for any infectious disease?

Family History

Has a member of your immediate family died from a chronic illness or disease?

Are there any significant inherited diseases or genetic conditions in your family that you are aware of?

Mental Health Questions

Have you ever received a psychiatric diagnosis (DSM IV) from a mental health professional, for any of the following; psychophrenia, psychotic episodes, personality disorder, major depression, generalized anxiety disorder. If yes, please specify:

Are you currently under the care of a psychiatrist or any other mental health professional? If yes, please specify:

Menstrual History

At what age did you get your first period?

Do you get mid-cycle discomfort or vaginal mucus at your fertile time (ovulation)?

Do you use a pad or a tampon or both?

Do You Get Clots With Your Period?

Are your periods excessively heavy or painful? If they are painful, what painkillers do you take?

Do you notice bleeding between periods?

How often do your periods come?

How long do they generally last?

Date of Last Menstrual period?

Obstetric History

Have Been Pregnant Before

Obstetric History

Please provide any information you can below

Number Of Pregnancies

Number Of Deliveries

Number Of Live Births

Number Of Term Pregnancies 38-42 Weeks

Number Of Preterm Pregnancies

Number Of Ectopic Pregnancies

Number Of Spontaneous Abortions

Number Of Therapeutic Abortions

Number Of Still Births

Number Of Neonatal Deaths

Pregnancy 1

Pregnancy1 Gestational Age Weeks

Pregnancy1 Pregnancy Outcome

Pregnancy1 Mode Of Delivery

Pregnancy1 Delivery Outcome

Pregnancy1 Other /Any Complications

Other pregnancies?

Pregnancy 2

Pregnancy2 Gestational Age Weeks

Pregnancy2 Pregnancy Outcome

Pregnancy2 Mode Of Delivery

Pregnancy2 Delivery Outcome

Pregnancy2 Other / Any Complications

Other pregnancies?

Pregnancy 3

Pregnancy3 Gestational Age Weeks

Pregnancy3 Pregnancy Outcome

Pregnancy3 Mode Of Delivery

Pregnancy3 Delivery Outcome

Pregnancy3 Other / Any Complications

Other pregnancies?

Pregnancy 4

Pregnancy4 Gestational Age Weeks

Pregnancy4 Pregnancy Outcome

Pregnancy4 Mode Of Delivery

Pregnancy4 Delivery Outcome

Pregnancy4 Other / Any Complications

Other pregnancies?

Pregnancy 5

Pregnancy 5 Gestational Age Weeks

Pregnancy 5 Pregnancy Outcome

Pregnancy 5 Mode Of Delivery

Pregnancy 5 Delivery Outcome

Pregnancy 5 Other / Any Complications

Previous Treatment

Have you had previous fertility treatment

Previous Treatment 1

Please provide as much information as you are able to

Treatment Date

Treatment1 Treatment Type

Treatment1 Drugs Days

Treatment1 Follicles Eggs

Treatment1 Injected Fertilised

Treatment1 Number Of Embryos Transferred

Treatment1 Embryo Day Quality

Treatment1 Number Day Frozen

Treatment1 Outcome

Treatment1 Comments

Other treatment?

Treatment 2

Treatment Date

Treatment 2 Treatment Type

Treatment 2 Drugs Days

Treatment 2 Follicles Eggs

Treatment 2 Injected Fertilised

Treatment 2 Number Of Embryos Transferred

Treatment 2 Embryo Day Quality

Treatment 2 Outcome

Treatment 2 Comments

Other treatment?

Treatment 3

Treatment Date

Treatment 3 Treatment Type

Treatment 3 Drugs Days

Treatment 3 Follicles Eggs

Treatment 3 Injected Fertilised

Treatment 3 Number Of Embryos Transferred

Treatment 3 Embryo Day Quality

Treatment 3 Number Day Frozen

Treatment 3 Outcome

Treatment 3 Comments

Other treatment?

Treatment 4

Treatment Date

Treatment 4 Treatment Type

Treatment 4 Drugs Days

Treatment 4 Follicles Eggs

Treatment 4 Injected Fertilised

Treatment 4 Number Of Embryos Transferred

Treatment 4 Embryo Day Quality

Treatment 4 Number Day Frozen

Treatment 4 Outcome

Treatment 4 Comments

Other treatment?

Treatment 5

Treatment Date

Treatment 5 Treatment Type

Treatment 5 Drugs Days

Treatment 5 Follicles Eggs

Treatment 5 Injected Fertilised

Treatment 5 Number Of Embryos Transferred

Treatment 5 Embryo Day Quality

Treatment 5 Number Day Frozen

Treatment 5 Outcome

Treatment 5 Comments

Male Medical History

Please complete this form to the best of your knowledge. If there are any question you are uncertain about, do not worry. The details will be discussed with the doctor at the first appointment.

The form will take some time to complete. if you have any questions or queries, please do not hesitate to contact us.

If you have further information, medical records or otherwise, please bring them to the first appointment so that your doctor can review them.

Are You Currently On Any Medications?

Do You Have Any General Medical Complaints At Present

Have You Had Any Illnesses Or Been Treated For Any Medical Condition In The Past

Are You Currently Attending A Medical Doctor Or Being Treated For A Medical Condition

Male Fertility/Andrology

Have You Ever Had A Semen Analysis Carried Out

If Yes What Was The Result

If Yes, have you had any difficulty producing a sample in a clinic setting?

Have You Been Responsible For Any Pregnancies In The Past Number

Have You Ever Experienced A Groin Injury Or Undergone Groin Surgery

Have You Any History Of Operations Involving The Reproductive System

Do You Have Undescended Testicles

Did You Ever Have Mumps

If Yes Was This As A Child Or An Adult

Male Partner: Do You Have Any Concerns About Your Sexual Life

Male Social History

If you smoke how many cigarettes do you smoke per day?

If you are no longer a smoker, when did you give up smoking?

If you drink alcohol, how many units do you consume per week?

Do you or have you taken any form of recreational drugs?

Where have you recently travelled to? (Last Six Months)

Have you ever travelled to/into an area known to be high medical risk for any infectious disease?

Male Mental Health Questions

Have you ever received a psychiatric diagnosis (DSM IV) from a mental health professional, for any of the following; psychophrenia, psychotic episodes, personality disorder, major depression, generalized anxiety disorder. If yes, please specify:

Are you currently under the care of a psychiatrist or any other mental health professional? If yes, please specify:

Your Partner

Do you have a partner?

Your Partner

Partners name

Partners gender

Partners Date of Birth

Partners email address

Partners home telephone

Ok to leave a message?

Partners Work telephone

Ok to leave a message?

Partners mobile telephone

Ok to leave a message?

Partners occupation

Partners known allergies

Partners GP name

Partners GP address

Female Partner Medical History

Height

Weight

Have you ever undergone an operation? (If so, please give details of all operations including the year).

Operations

Are you currently on any medications?

How long have you been trying to conceive?

Have you used contraception before?

Are you currently attending a medical doctor or being treated for an illness or medical condition?

Have you had any illness or been treated for a medical condition in the past?

Do you have any general medical complaints at present?

Are you currently using any non fertility medication?

Female Partner Social History

If you smoke, how many cigarettes do you smoke per day?

If you are no longer a smoker, when did you give up smoking?

If you drink alcohol how many units do you consume per week?

Do you or have you taken any form of recreational drugs?

Where have you recently travelled to? (last six months)

Have you every travelled to or into an area known to be high medical risk for any infectious disease?

Female Partner Family History

Has a member of your immediate family died from a chronic illness or disease?

Are there any significant inherited diseases or genetic conditions in your family that you are aware of?

Female Partner Mental Health Questions

Have you ever received a psychiatric diagnosis (DSM IV) from a mental health professional, for any of the following; psychophrenia, psychotic episodes, personality disorder, major depression, generalized anxiety disorder. If yes, please specify:

Are you currently under the care of a psychiatrist or any other mental health professional? If yes, please specify:

Female Partner Menstrual History

At what age did you get your first period?

Do you get mid-cycle discomfort or vaginal mucus at your fertile time (ovulation)?

Do you use a pad or a tampon or both?

Do You Get Clots With Your Period?

Are your periods excessively heavy or painful? If they are painful, what painkillers do you take?

Do you notice bleeding between periods?

How often do your periods come?

How long do they generally last?

Date of Last Menstrual period?

Female Partner Obstetric History

Have Been Pregnant Before

Female Partner Obstetric History

Please provide any information you can below

Number Of Pregnancies

Number Of Deliveries

Number Of Live Births

Number Of Term Pregnancies 38-42 Weeks

Number Of Preterm Pregnancies

Number Of Ectopic Pregnancies

Number Of Spontaneous Abortions

Number Of Therapeutic Abortions

Number Of Still Births

Number Of Neonatal Deaths

Female Partner Pregnancy 1

Pregnancy1 Gestational Age Weeks

Pregnancy1 Pregnancy Outcome

Pregnancy1 Mode Of Delivery

Pregnancy1 Delivery Outcome

Pregnancy1 Other /Any Complications

Other pregnancies?

Female Partner Pregnancy 2

Pregnancy2 Gestational Age Weeks

Pregnancy2 Pregnancy Outcome

Pregnancy2 Mode Of Delivery

Pregnancy2 Delivery Outcome

Pregnancy2 Other / Any Complications

Other pregnancies?

Female Partner Pregnancy 3

Pregnancy3 Gestational Age Weeks

Pregnancy3 Pregnancy Outcome

Pregnancy3 Mode Of Delivery

Pregnancy3 Delivery Outcome

Pregnancy3 Other / Any Complications

Other pregnancies?

Female Partner Pregnancy 4

Pregnancy4 Gestational Age Weeks

Pregnancy4 Pregnancy Outcome

Pregnancy4 Mode Of Delivery

Pregnancy4 Delivery Outcome

Pregnancy4 Other / Any Complications

Other pregnancies?

Female Partner Pregnancy 5

Pregnancy 5 Gestational Age Weeks

Pregnancy 5 Pregnancy Outcome

Pregnancy 5 Mode Of Delivery

Pregnancy 5 Delivery Outcome

Pregnancy 5 Other / Any Complications

Female Partner Previous Treatment

Have you had previous fertility treatment

Female Partner Previous Treatment 1

Please provide as much information as you are able to

Treatment Date

Treatment1 Treatment Type

Treatment1 Drugs Days

Treatment1 Follicles Eggs

Treatment1 Injected Fertilised

Treatment1 Number Of Embryos Transferred

Treatment1 Embryo Day Quality

Treatment1 Number Day Frozen

Treatment1 Outcome

Treatment1 Comments

Other treatment?

Female Partner Treatment 2

Treatment Date

Treatment 2 Treatment Type

Treatment 2 Drugs Days

Treatment 2 Follicles Eggs

Treatment 2 Injected Fertilised

Treatment 2 Number Of Embryos Transferred

Treatment 2 Embryo Day Quality

Treatment 2 Outcome

Treatment 2 Comments

Other treatment?

Female Partner Treatment 3

Treatment Date

Treatment 3 Treatment Type

Treatment 3 Drugs Days

Treatment 3 Follicles Eggs

Treatment 3 Injected Fertilised

Treatment 3 Number Of Embryos Transferred

Treatment 3 Embryo Day Quality

Treatment 3 Number Day Frozen

Treatment 3 Outcome

Treatment 3 Comments

Other treatment?

Female Partner Treatment 4

Treatment Date

Treatment 4 Treatment Type

Treatment 4 Drugs Days

Treatment 4 Follicles Eggs

Treatment 4 Injected Fertilised

Treatment 4 Number Of Embryos Transferred

Treatment 4 Embryo Day Quality

Treatment 4 Number Day Frozen

Treatment 4 Outcome

Treatment 4 Comments

Other treatment?

Female Partner Treatment 5

Treatment Date

Treatment 5 Treatment Type

Treatment 5 Drugs Days

Treatment 5 Follicles Eggs

Treatment 5 Injected Fertilised

Treatment 5 Number Of Embryos Transferred

Treatment 5 Embryo Day Quality

Treatment 5 Number Day Frozen

Treatment 5 Outcome

Treatment 5 Comments

Male Partner Medical History

Are You Currently On Any Medications?

Do You Have Any General Medical Complaints At Present

Have You Had Any Illnesses Or Been Treated For Any Medical Condition In The Past

Are You Currently Attending A Medical Doctor Or Being Treated For A Medical Condition

Male Partner Fertility/Andrology

Have You Ever Had A Semen Analysis Carried Out

If Yes What Was The Result

If Yes, have you had any difficulty producing a sample in a clinic setting?

Have You Been Responsible For Any Pregnancies In The Past Number

Have You Ever Experienced A Groin Injury Or Undergone Groin Surgery

Have You Any History Of Operations Involving The Reproductive System

Do You Have Undescended Testicles

Did You Ever Have Mumps

If Yes Was This As A Child Or An Adult

Male Partner: Do You Have Any Concerns About Your Sexual Life

Male Partner Social History

If you smoke how many cigarettes do you smoke per day?

If you are no longer a smoker, when did you give up smoking?

If you drink alcohol, how many units do you consume per week?

Do you or have you taken any form of recreational drugs?

Where have you recently travelled to? (Last Six Months)

Have you ever travelled to/into an area known to be high medical risk for any infectious disease?

Male Partner Mental Health Questions

Have you ever received a psychiatric diagnosis (DSM IV) from a mental health professional, for any of the following; psychophrenia, psychotic episodes, personality disorder, major depression, generalized anxiety disorder. If yes, please specify:

Are you currently under the care of a psychiatrist or any other mental health professional? If yes, please specify:

Additional Comments

Any additional comments

Do you have any special requirements you would like to make us aware of?

Authorisation

Your records are considered confidential and will not be released without your consent and signature.

I hereby authorise the Rotunda IVF to release information to my GP and myself.

Please indicate yes or no