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Fertility History Form

 

 

Personal Information

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* Male Female

Marital Status


Medical History

1.Do you have any known medical conditions??
2.Are you currently taking any medications？
3.Have you undergone any surgeries?
4.Do you have any allergies?
5.Do you smoke?
6.Do you consume alcohol?

Reproductive History (For Women)

1.Menstrual History:
Regular Irregular
2.Have you ever been pregnant?
3.Have you experienced any of the following?
Painful periods Heavy bleeding Irregular periods None of the above
4.Have you been diagnosed with any reproductive health conditions?

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Consultation time

  • calendar_monthMonday ~ Friday
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    • Morning
      10:00 - 12:00
    • Afternoon
      02:00 - 05:00
    • Night
      06:00 - 09:30
  • calendar_monthSaturday
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    • Morning
      10:00 - 12:00

Dr. Shiuh Young Chang FB

Clinic: Children are treasures and full of joy (Professor Shiuh Young Chang)

 

Dr. Hsu Pei-Yang FB

Dr. Hsu Pei-Yang: Pregnancy Supplement Station

No. 580, Boai 2nd Road, Zuoying District,
Kaohsiung City
IVF professional organization
Call Now for Inquiries
Fax: 07-5508732
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