Information for a first visit
Pain
Since when?: |
.and how did it started ……………………. |
months/years |
Type of Pain : |
during periods : …/3 ; every day : …/3 ; pain at intercourse : …/3 |
scoring : |
|
pain when going go to the toilet : …/3 ; pain during micturition : …/3.during periods |
from 1 to 3 |
Where Pain ? |
lower back ? hypogastric ?
|
circle |
Radiation to |
lower back, anterior side of the legs up to the knee le/ri, the whole leg le/ri , perineal (anus and vagina) |
circle |
Infertility
Since when?: |
…………………….. |
months/years |
Exploration |
ovulation |
complete |
|
transport |
|
|
implantation |
|
|
cervical function |
|
|
spermiogram |
|
IVF |
number : ….. ; where ? Result ? |
|
Previous investigations
Ultrasound |
…………………….. |
when ? by whom ? results ? |
Laparoscopy |
………………………… |
|
IVP |
|
|
Contrast Enema |
|
|
Others |
MRI CAT scan |
|
Surgery ?
where ? by whom ? Laparoscopy ?, laparotomy ? ; bowel resection ? Complete ?
Medical treatment ?
which treatment, before and after surgery
Bring all reports you have
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