IVF病史资料男性

试管婴儿治疗意向患者资料患者信息（男性）ENTRYFORMMAN个人资料PERSONALDETAILS填表日期Dateofentry:FORMTEXT     姓名Name：配偶姓名Partner’sname：FORMTEXT     婚史Lengthofyourrelationship：FORMTEXT     住址Adress：FORMTEXT     出生日期Dateofbirth：FORMTEXT      配偶生日Partner’sdateofbirth：FORMTEXT     联系电话Telephonenumber(daytime)：FORMTEXT      紧急联系电话Telephonenumber(evening)：FORMTEXT     手机Mobile：FORMTEXT     电子信箱e-mail：FORMTEXT     职业Currentemployment：FORMTEXT     主治医生信息DETAILSOFDOCTOR FORMCHECKBOX首诊noreferringdoctor内科医生Familydoctor： 妇科医生Gynaecologist姓名Name：姓名Name：FORMTEXT     地址Adress:：FORMTEXT      地址Adress：FORMTEXT     电话Tel.：FORMTEXT      电话Tel.：FORMTEXT     传真Fax：FORMTEXT      传真Fax：FORMTEXT     专业（科室）Practice： 专业(科室)Practice：FORMTEXT     病史MEDICALHISTORY体重Weight:FORMTEXT     kg 身高Height:FORMTEXT     cm血型Bloodtype:FORMTEXT     去年你体重是否减少超过10公斤Haveyoulostmorethan10kginthelastyear?FORMCHECKBOX否No FORMCHECKBOX是Yes你是否喜欢吃特殊的东西或者是有特殊的饮食习惯Areyouonaspecialdietordoyouhavespecialdietaryhabits?FORMCHECKBOX否NoFORMCHECKBOX是Yes请列举(pleasespecify)FORMTEXT     是否定期运动？Doyouexerciseregulary?FORMCHECKBOX否NoFORMCHECKBOX是Yes请列举(pleasespecify)一周运动几次（多少小时）Howmanyhoursaweek?服兵役期间是否暴露在以下环境内：Haveyoueverbeenexposedduringyourmilitaryservicetooneofthefollowing:FORMCHECKBOX荒地heath FORMCHECKBOX化学产品chemicalproductsFORMCHECKBOX有毒气体poisonousodours FORMCHECKBOX放射radiationFORMCHECKBOX其他other请详细描述(pleasespecify)FORMTEXT     FORMTEXT     是否定期桑拿？Doyouregularlygotothesauna,takesteambathsorhotjacuzzis?FORMCHECKBOX否NoFORMCHECKBOX是Yes腹部、腹股沟部、生殖器是否做过手术？Haveyoueverbeenoperateduponinyourabdomen,groinareaorgenitals?FORMCHECKBOX否NoFORMCHECKBOX是Yes请详细描述什么手术、什么时候(pleasespecifywhatandwhen)FORMTEXT     是否有以下情况:Doyousuffer,orhaveyoueversuffered,from:FORMCHECKBOX过敏Allergies FORMCHECKBOX癫痫Epilepsy FORMCHECKBOX胸痛/胸敏感Painful/sensitivechestFORMCHECKBOX贫血Anaemia FORMCHECKBOX毛发过度生长Excessivehairgrowth FORMCHECKBOX寄生虫感染ParasiticinfectionFORMCHECKBOX阑尾炎Appendictis FORMCHECKBOX胆囊问题Gallbladderproblems FORMCHECKBOX盆腔感染PelvicinfectionFORMCHECKBOX关节炎Arthritis FORMCHECKBOX风疹Germanmeasles FORMCHECKBOX肺炎PneumoniaFORMCHECKBOX输血Bloodtransfusion FORMCHECKBOX淋病Gonorrhoea FORMCHECKBOX嗅觉低下PoorsenseofsmellFORMCHECKBOX衣原体感染Chlamydiainfection FORMCHECKBOX心脏病Heartcondition FORMCHECKBOX风湿RheumatismFORMCHECKBOX慢性支气管炎ChronicbronchitisFORMCHECKBOX肝炎Hepatitis FORMCHECKBOX猩红热ScarletfeverFORMCHECKBOX慢性头疼ChronicheadachesFORMCHECKBOX疱疹Herpes FORMCHECKBOX梅毒SyphilisFORMCHECKBOX结肠炎Colitis FORMCHECKBOX高血压Highbloodpressure FORMCHECKBOX甲状腺问题ThyroidproblemFORMCHECKBOX色盲Colourblindness FORMCHECKBOX肾脏感染Kidneyinfection FORMCHECKBOX肺结核TuberculosisFORMCHECKBOX抽搐Convulsions FORMCHECKBOX肝脏问题Liverproblems FORMCHECKBOX溃疡UlcersFORMCHECKBOX糖尿病Diabetes FORMCHECKBOX失去平衡Lossofbalance FORMCHECKBOX尿道炎UrethritisFORMCHECKBOX头晕Dizziness FORMCHECKBOX麻疹Measles FORMCHECKBOX阴道炎Vaginitis FORMCHECKBOX子宫内膜异位症Endometriosis FORMCHECKBOX神经系统问题Neurologicalproblems FORMCHECKBOX视觉障碍Visualdisturbanc 腹部或者生殖器做过放射治疗？Haveyoueverhadradiotherapynearyourabdomenorgenitals?FORMCHECKBOX否No FORMCHECKBOX是Yes是否进行过癌症治疗？Haveyoueverbeentreatedforcancer?FORMCHECKBOX否No FORMCHECKBOX是Yes请详细描述何种疾病及何时(pleasespecifywhatandwhen) FORMTEXT     FORMTEXT     FORMTEXT     FORMTEXT     去年是否服过药？Haveyoutakenany(prescribed)medicationinthepastyear?FORMCHECKBOX否No FORMCHECKBOX是Yes请详细描述何种药及服药原因(pleasespecifywhichmedicationandwhyyouweretakingit)去年是否服用过处方药？Haveyoutakenanyover-the-countermedicationinthepastyear?FORMCHECKBOX否No FORMCHECKBOX是Yes请详细描述药品名及服药原因(pleasespecifywhichmedicationandwhyyouweretakingit)FORMTEXT     FORMTEXT     过去三到四个月是否感冒（体温高于38℃）？Haveyouhadafeverinthelast3to4months(higherthan38°C)?FORMCHECKBOX否No FORMCHECKBOX是Yes是否有过下列情况？Doyouuse,orhaveyoueverusedthefollowing?FORMCHECKBOX是否酗酒（如果是，一天喝多少？）Alcohol(ifyes,howmanyglassesaday)FORMTEXT     FORMTEXT     FORMCHECKBOX是否抽烟（如果是，一天抽多少？）Tobacco(ifyes,howmanycigarettesorcigarsaday)FORMTEXT     FORMTEXT     FORMCHECKBOX是否有毒瘾（如果有，什么毒品，依赖到何种程度）Drugs(ifyes,whatandtowhatextend)FORMTEXT     FORMTEXT     不孕不育史MEDICALHISTORY儿童期，两个睾丸是否下降到阴囊？Whenyouwereachild,hadbothtestesdescendedintothescrotum?FORMCHECKBOX否No FORMCHECKBOX是Yes是否割过包皮Haveyoubeencircumcised?FORMCHECKBOX否No FORMCHECKBOX是Yes什么时候开始长胡子并开始定期刮胡子?Atwhatagedidyoustarttogrowabeardorneedtoshaveregularly?结过多少次婚？Howmanytimeshaveyoubeenmarried?是否和其他配偶有过生育史Haveyoueverhadachildwithanotherpartner?FORMCHECKBOX否No FORMCHECKBOX是Yes配偶多长时间怀孕?(howlongdidittaketomakeyourpartnerpregnant）FORMTEXT     FORMTEXT     FORMTEXT     与其他配偶是否也有困难？Didyoualsoexperienceproblemsmakingadifferentpartnerpregnant?FORMCHECKBOX否No FORMCHECKBOX是Yes是否有勃起问题？Doyouhaveanytroublegettinganerection?FORMCHECKBOX否No FORMCHECKBOX是Yes在勃起时间上是否有问题？Doyouhaveanytroublemaintaininganerection?FORMCHECKBOX否No FORMCHECKBOX是Yes是否有射精问题？Doyouhavetroubleejaculating?FORMCHECKBOX否No FORMCHECKBOX是Yes FORMCHECKBOX早泄Premature(toosoon)FORMCHECKBOX逆行射精Retrograde、dryejaculation‘ 性交时能否感觉到精液在女方阴道内停留？Doyoufeelthatsomeofyoursemenisdepositedinthevaginaduringintercourse?FORMCHECKBOX否No FORMCHECKBOX是Yes自慰时是否出现过高潮不射精情况？Doyoueverhaveorgasmwithoutejaculationwhenyoumasturbate?FORMCHECKBOX否No FORMCHECKBOX是Yes射精时，阴茎是否还有射出过其他液体？Doyouhaveanydischargefromthepenisapartfromejaculation?FORMCHECKBOX否No FORMCHECKBOX是Yes每周同房次数？Howmanytimesaweekdoyouandyourpartnerhavesexualintercourse?FORMTEXT     FORMTEXT     FORMTEXT     排卵期同房次数（尤其是配偶两次月经之间的时期）Howmanytimesdoyouhavesexualintercoursearoundthetimeofovulation(approximatelyhalfwaythroughyourpartner’smenstrualcycle)?FORMTEXT     FORMTEXT     FORMTEXT     近期，性欲是否变化？Haveyounoticedachangeinyourlibidolately?FORMCHECKBOX否No FORMCHECKBOX是Yes家族病史FAMILYHISTORY家族有否有不孕不育史Isthereahistoryoffertilityproblemsinyourfamily?FORMCHECKBOX否No FORMCHECKBOX是Yes与本人关系(ifyes,who?)FORMTEXT     FORMTEXT     FORMTEXT     家族是否有先天性疾病或者激素史？Isthereanyhistoryofhormonalorcongenitaldisordersinyourfamily?FORMCHECKBOX否No FORMCHECKBOX是Yes与本人关系(ifyes,who?)：在你的家庭中：Inyourfamily:FORMCHECKBOX是否有过异常的新生儿？ haveanychildrenbeenbornwithabnormalities?FORMCHECKBOX是已知的先天性疾病么？ arethereanyknowncongenitaldisorders?FORMCHECKBOX是否有女性或男性患有癌症? dothemenorwomenhabeproblemswithcancer?FORMCHECKBOX否NoFORMCHECKBOX是Yes请详细描述（病种、与本人关系）FORMTEXT     FORMTEXT     (pleasespecifywhatandwho)不孕不育治疗史FERTILITYTREATMENTHISTORY备孕多长时间？Howlongareyouandyourpartnertryingtogetpregnant?(month/year)FORMTEXT     FORMTEXT     FORMTEXT     之前是否治疗过不孕不育Haveyoubeentreatedforinfertilitybefore?FORMCHECKBOX否No FORMCHECKBOX是Yes治疗时间及主治医师(whenwasistandwhowasyourdoctor?)FORMTEXT     FORMTEXT     FORMTEXT     经由医生诊断不孕不育的病因？Whatcauseofreducedfertilitywasdiagnosed?FORMTEXT     FORMTEXT     FORMTEXT     做过以下何种检验及检验结果Whichofthefollowingtestshaveyouhadandwhatwastheresult(ifknown)?检验Test检验时间Year结果ResultFORMCHECKBOX精液分析SemenanalysisFORMTEXT     FORMCHECKBOX衣原体检查ChlamydiatestFORMTEXT     FORMCHECKBOX支原体检查MycoplasmatestFORMTEXT     FORMCHECKBOX抗体检查AntibodytestFORMTEXT     FORMCHECKBOX染色体检查Chromosometest(karyotype)FORMTEXT     FORMCHECKBOX睾丸活检TesticularbiopsyFORMTEXT     FORMCHECKBOX睾丸超声TesticularultrasoundFORMTEXT     FORMCHECKBOX激素检查（FSH，LH，PRL检测，睾酮）Hormonaltest(FSH,LH,prolactin,testosterone)FORMTEXT     FORMCHECKBOX甲状腺检查ThyroidtestsFORMTEXT     FORMCHECKBOX前列腺超声检查UltrasoundofprostateFORMTEXT     FORMCHECKBOX其他（请详细描述）Other(pleasespecify)FORMTEXT     是否做过精索静脉曲张手术？Haveyoueverhadvaricocele(varicoseveinsonthetests)repair?FORMCHECKBOX否No FORMCHECKBOX是Yes何时(ifso,when)是否做过输精管结扎术？Haveyoueverhadavasectomy(sterilisation)?FORMCHECKBOX否No FORMCHECKBOX是Yes何时(ifso,when)你的配偶是否有过生育史（和其他男性）？Hasyourpartnerhadchildrenwithanotherman?FORMCHECKBOX否NoFORMCHECKBOX是Yes何时(when?)FORMTEXT     FORMTEXT     你的伴侣是否进行过不孕不育治疗？Isyourpartnerseeingadoctorforinfertilityevaluation?FORMCHECKBOX否NoFORMCHECKBOX是Yes主治医师：(pleasespecifydoctor)FORMTEXT     FORMTEXT     医生是否诊断你的配偶有不孕不育问题？Doesthatdoctorfeelthatyourpartnerhasaninfertilityproblem?FORMCHECKBOX否NoFORMCHECKBOX是Yes病因及治疗方式(whatisthediagnosisandhasatreatmentbeenproposed?)使用过哪种治疗药物？Whatfertilitydrugshaveyoutaken?FORMCHECKBOX没用过NoneFORMCHECKBOX克罗米芬Clomiphenecitrate(Pergotime®,Clomid)FORMCHECKBOX他莫昔芬（他莫昔芬®，tamizan®）Tamoxifen(Nolvadex®,Tamizan®)FORMCHECKBOXHMG （美诺孕喜美康）hMG(Menopur®,Humegon®) FORMCHECKBOX睾酮Testosterone(Proviron®,Sustanon®,Testocaps®,Understo