March 10, 2010, 10:41 am
 

THE VIRK-ROTUNDA Free Second Opinion

Rotunda-Virk Jalandhar would be happy to provide a second opinion on your problem. This is a free service and we would be glad to answer your queries within 24 hours. Please fill in the following details. This should take about 15 minutes. This is basic medical information, which every infertile couple must know. While you don't have to fill in all the information, please remember that the more the detail you provide and the better the question you ask, the better our answer will be! All emails are personally answered by Dr. Kulwinder Kaur, Dr. S.P.S Virk, Dr. Harpreet Kaur and Dr. Geeta Digra, so you can rest reassured that your privacy and confidentiality are strictly maintained.

Full Name of Husband  
Full Name of Wife  
Address  
Pincode  
Country  
Email Address  
This is the email through which we will correspond with you.
Contact Number  

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General Information of the Couple
How long have you been married?
Years Months
How long have you been trying to get pregnant?
Years Months
How long have you been trying to get pregnant with the help of a doctor?
Years Months
Your consulting doctor was a
Why do you think you are not getting pregnant? Send us your diagnosis

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Fertility History of Female Partner
What is your age?
Years Months
What is your height?
Feet Inches
What is your weight?
Kgs
Occurance of Menstrual Periods
Are they regular?
Have you been told you have Endometriosis?
Have you ever had a pelvic inflammatory disease?
Have you had any pregnancies with the present partner? If "yes", please specify specify the number of the times with the respective years.
Have you had pelvic surgeries? If "yes", please specify which ones, which years, and what were the findings.
Have you had any pregnancies with a previous partner? If "yes", please specify the number of the times with the respective years and outcome.
Have you had any miscarriages or abortions? If "yes", please specify the number of the times with the respective years and how many weeks pregnant were you each time.
Have you had any tubal(ectopic) pregnancies? If "yes", please specify the number of the times with the respective years and outcome.
Have you had any live births? If "yes", please specify the number of the times with the respective years.
Do you have any medical problems or medications? If "yes", please specify details.

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Fertility History of Male Partner
What is your age?
Years Months
What is your height?
Feet Inches
What is your weight?
Kgs
Sperm Count
  Million per ml
Sperm Motility
%
Do you have problems with erection or ejaculation? If "yes", please specify in detail.
Have you had any pregnancies with a previous partner? If "yes", please specify the number of the times with the respective years and outcome.
Do you have any medical problems or medications? If "yes", please specify details.
In case of an abnormal semen analysis report , please specify with respective details and dates of the reports

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Medical Test History
Hysterosalpingogram (X-ray of the uterus and tubes)
 
Date  
Result  
Laparoscopy (Telescope placed through the belly button to see inside your abdomen)
 
Date  
Result  
Hysteroscopy (Telescope placed into the uterus through the vagina to see the inside of the uterus)
 
Date  
Result  
Hormonal Blood Tests (Please enter the values of your blood test reports below)
 
Date  
Result  
FSH
 
Date  
Result  
LH
 
Date  
Result  
 
Prolactin
 
Date  
Result  
 
TSH
 
Date  
Result  
Others
 
Name of the Test  
Date  
Result  

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Medical Treatment History
Ultrasound Monitoring
 
Number of Treaments
and respective dates 		 
Result  
Clomiphene Stimulation with Intercourse
 
Number of Treaments
and respective dates 		 
Result  
Clomiphene Stimulation with Insemination
 
Number of Treaments
and respective dates 		 
Result  
HMG Stimulation with Intercourse
 
Number of Treaments
and respective dates 		 
Result  
Insemination without any Stimulation
 
Number of Treaments
and respective dates 		 
Result  
Injectable HMG Stimulation with Insemination
 
Number of Treaments
and respective dates 		 
Result  

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