|
Name of Fertility Practice
|
Physician
|
|
Hysterosalpingogram
|
Date test taken
|
|
Result
|
|
|
Endometrial Biopsy
|
Date test taken
|
|
Result
|
|
|
Clomid Challenge
|
Date test taken
|
|
Result
|
|
|
Follicle Stim Hormone
|
Date test taken
|
|
Result
|
|
|
Luteinizing Hormone Test
|
Date test taken
|
|
Result
|
|
|
Estradiol Test
|
Date test taken
|
|
Result
|
|
|
Progesterone Test
|
Date test taken
|
|
Result
|
|
|
Prolactin Test
|
Date test taken
|
|
Result
|
|
|
Laproscopy Test
|
Date test taken
|
|
Result
|
|
|
Western diagnostic Test
|
Date test taken
|
|
Result
|
|
|
Any additional tests taken
|
Date test taken
|
|
Result
|
|
|
GYN related surgeries Date
|
Outcome
|
|
Intrauterine Insemination
|
In Vitro Fertilization (IVF)
|
|
Gamete Intrafallopian Transfer
|
Zygote Intrafallopian Transfer
|
|
Male Factor
|
|
|
Sperm Count (#/cc)
|
Sperm Motility (% moving)
|
|
Sperm Morphology
|
|
|
Other Past Treatments
|
|
