|
G AND P STATUS (age is includ.)
• • •
|
IF HX
|
|
PLAN FOR THIS CYCLE
|
PLAN FOR NEXT CYCLE
|
|
VISIT # 1
|
|
|
VISIT DATE
• • •
|
CYCLE DAY
|
|
|
|
|
R OVARY (mm)
|
L OVARY (mm)
|
|
ENDOMETRIAL LINING (mm)
|
TRILAMINAR
|
|
IUI STATS PRE WASH VOL/COUNT/MOT
|
IUI STATS POST WASH VOL/COUNT/MOT
|
|
POST IUI MEDS
• • •
|
ADDITIONAL COMMENTS
|
|
ASSESSMENT & PLAN
|
|
|
CPT & ICD
• • •
|
ADDITIONAL CPT/ICD9
|
|
VISIT # 2
|
|
|
VISIT DATE
• • •
|
CYCLE DAY
|
|
|
|
|
R OVARY (mm)
|
L OVARY (mm)
|
|
ENDOMETRIAL LINING (mm)
|
TRILAMINAR
|
|
IUI STATS PRE WASH VOL/COUNT/MOT
|
IUI STATS POST WASH VOL/COUNT/MOT
|
|
POST IUI MEDS
• • •
|
ADDITIONAL COMMENTS
|
|
ASSESSMENT & PLAN
|
|
|
CPT & ICD
• • •
|
ADDITIONAL CPT/ICD9
|
|
VISIT # 3
|
|
|
VISIT DATE
• • •
|
CYCLE DAY
|
|
|
|
|
R OVARY (mm)
|
L OVARY (mm)
|
|
ENDOMETRIAL LINING (mm)
|
TRILAMINAR
|
|
IUI STATS PRE WASH VOL/COUNT/MOT
|
IUI STATS POST WASH VOL/COUNT/MOT
|
|
POST IUI MEDS
• • •
|
ADDITIONAL COMMENTS
|
|
ASSESSMENT & PLAN
|
|
|
CPT & ICD
• • •
|
ADDITIONAL CPT/ICD9
|
|
VISIT # 4
|
|
|
VISIT DATE
• • •
|
CYCLE DAY
|
|
|
|
|
R OVARY (mm)
|
L OVARY (mm)
|
|
ENDOMETRIAL LINING (mm)
|
TRILAMINAR
|
|
IUI STATS PRE WASH VOL/COUNT/MOT
|
IUI STATS POST WASH VOL/COUNT/MOT
|
|
POST IUI MEDS
• • •
|
ADDITIONAL COMMENTS
|
|
ASSESSMENT & PLAN
|
|
|
CPT & ICD
• • •
|
ADDITIONAL CPT/ICD9
|
|
VISIT # 5
|
|
|
VISIT DATE
• • •
|
CYCLE DAY
|
|
|
|
|
R OVARY (mm)
|
L OVARY (mm)
|
|
ENDOMETRIAL LINING (mm)
|
TRILAMINAR
|
|
IUI STATS PRE WASH VOL/COUNT/MOT
|
IUI STATS POST WASH VOL/COUNT/MOT
|
|
POST IUI MEDS
• • •
|
ADDITIONAL COMMENTS
|
|
ASSESSMENT & PLAN
|
|
|
CPT & ICD
• • •
|
ADDITIONAL CPT/ICD9
|
|
VISIT # 6
|
|
|
VISIT DATE
• • •
|
CYCLE DAY
|
|
|
|
|
R OVARY (mm)
|
L OVARY (mm)
|
|
ENDOMETRIAL LINING (mm)
|
TRILAMINAR
|
|
IUI STATS PRE WASH VOL/COUNT/MOT
|
IUI STATS POST WASH VOL/COUNT/MOT
|
|
POST IUI MEDS
• • •
|
ADDITIONAL COMMENTS
|
|
ASSESSMENT & PLAN
|
|
|
CPT & ICD
• • •
|
ADDITIONAL CPT/ICD9
|
