Patient Medical FormHomePatient Medical Form Medical Record of the Patient (EN) 1st Visit/ Medical Record of the PatientPlease fill out your personal InformationDate / TimeReferral DoctorMarital statuse.g. SingleSingleMarriedPartnersDivorcedWidowedOtherSave & ResumePreviousNextWoman - Your personal InformationPlease fill out your personal InformationFirst NameLast NameDate of BirthYour Father's NameYour Mother's NameAddress Line 1e.g. Flat 5CityStateZip CodeCountrySelect CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelauBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDemocratic Republic of the Congo (Kinshasa)DenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRepublic of the Congo (Brazzaville)ReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabwePhone/MobileEmailOccupationI.D/Passport NumberDate Of Identity IssuancePlace Of Identity IssuanceSave & ResumePreviousNextMan - Your partner's InformationPlease fill out your partner's InformationPartner's First NamePartner's Last NamePartner's Date of BirthPartner's OccupationPartner's Father's NamePartner's Mother's NamePartner's AddressAddress Line 1Address Line 2CityStateZip CodeCountrySelect CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelauBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDemocratic Republic of the Congo (Kinshasa)DenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRepublic of the Congo (Brazzaville)ReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabwePartner's PhonePartner's EmailPartner's I.D/Passport NumberDate Of Identity IssuancePlace Of Identity IssuanceSave & ResumePreviousNextWoman - Your medical informationPlease fill out some of your personal medical informationQ1. Have you ever been pregnant? No YesHow many times?time(s)Q2. Have you been having unprotected sexual contact? No YesHow long?daysQ3. Is your period regular? No YesUnregular periodQ4. Do you have any kind of medical condition? (illness, syndrome, disability, etc) No YesDescribe your medical conditionQ5. Are you taking any medicine? No YesWhat medicineQ6. Do you have any allergies/to medication? No YesYour allergiesQ7. Have you ever been diagnosed with a gynecological issue?- Please make your Selection -NoUterine FibroidsEndometriosisPolycystic OvariesPolypsPelvic InflammationQ8. Have you undergone any operations in the past? No YesMention your operation(s)Q9. Have you ever made an IVF attempt? No YesChronological order and the outcomeQ10. Do you have family history of a medical condition or cancer? No YesDegree of relationship and the condition/cancerQ11. Do you smoke? No YesCigarettesper dayHow long?year(s)Q12. Any other overconsumption (ex. Alcohol) or substance abuse ? No YesDescritpionYour HeightcmYour WeightkgBlood group- Select -A+A-B+B-AB+AB-O+O-Eye colourHair colourSkin colorSave & ResumePreviousNextOther InformationSome description about this sectionYour Notes / CommentsI am interested for IVF with egg donation I am interested for IVF with egg donationI am interested for IVF sperm donor I am interested for IVF sperm donorSave & ResumePreviousNextMan - Your partner's medical informationPlease fill out some of your partner's medical informationHave you ever become a parent in the past? No YesParent timestime(s)Do you have any kind of medical condition? (illness, syndrome, disability, etc) No YesDescribe your medical conditionAre you taking any medicine? No YesWhat medicineDo you have any allergies?(if Yes, please mention ) No YesYour allergiesHave you undergone any operations in the past? No YesOperationsHave you ever had a problem with your reproductive organs? No YesProblems with reproductive organsDo you have family history of a medical condition or cancer? No YesMedical condition historyDo you smoke? No YesCigarettesper dayHow long?year(s)Any other overconsumption (ex. Alcohol) or substance abuse ? No YesDescritpionHeight (cm)Weight (kg)Blood group- Select -A+A-B+B-AB+AB-O+O-Eye colourHair colourSkin colorSave & ResumePreviousNextOther informationSome description about this sectionNotesSave & ResumePreviousNextGDPRPatient information for processing of personal data and consent formGdrp Fields I declare that I am aware of the above Information regarding processing of my personal data.*Gdrp Fields I declare that I wish to have my Identification and Contact Data used by GMG to send newsletters about new services and health products, offers and activities of GMG.*Gdrp Fields I declare that I consent to having my photos taken to monitor my health.* Previous Submit Form
