Summary of basic information (first visit)

初診資料摘要
Information about the wife Information about the husband
太太的資料 先生的資料
Full name
GERLIE O. DELA CRUZ MANOLO B. SY JR
全名
Date of
NOVEMBER 23,1978 JUNE 30, 1976
birth 生日
Age 年紀 39yrs. Old 42yrs. Old
Weight
(kg)
51kg 69kg
體重（公
斤）
Height
(cm)
163cm 165cm
身高（公
分）
Blood
Type TYPE O TYPE O
血型
Please scan the passport, then send it back to ivftaiwan@gmail.com
Passport 請將護照掃描後寄到我們的信箱
number
護照號碼

Such as driver license, please scan the 2nd ID then send it back to ivftaiwan@gmail.com
Second ID 請將第二證件掃描後寄到我們的信箱
第二證件號
碼

Marriage
Please scan your marriage certificate, then send it back to ivftaiwan@gmail.com
Certificate
請將結婚證書掃描後寄到我們的信箱
結婚證書
Mobile
phone
+639957831418 +639151324078
number
手機號碼
Landline
number NONE NONE
市話號碼
Email
address gdelacruz_78@yahoo.com manolosy@yahoo.com
電子信箱
Facebook
account Ghie d sy Manolo sy
臉書帳號
Contact Postal code 郵遞區號 2416 Postal code 郵遞區號 2416
address 697 A.B. NAVATO ST. POBLACION, BUGALLON, 697 A.B. NAVATO ST. POBLACION,
通訊地址 PANGASINAN BUGALLON, PANGASINAN
Any habits NO - Drinking 喝酒 YES - Drinking 喝酒
煙酒習慣 NO - Smoking 抽煙 NO - Smoking 抽煙
□Other(其他，請載明) □Other(其他，請載明)
□Not taking any（現在並無用藥）
X - Yes, please provide the medicine name here: Aspirin EC, □Not taking any（現在並無用藥）
Medicine
Humamet, COQ10, Probiotics, DHA, Folic Acid, Fern-C, X - Yes, please provide the medicine name here:
taken now
Transderm-Nitro 5mg Daflon 500, Glutathione, COQ10, Fern-C, Count
用藥狀況
boost for Men, Megaman capsule

Allergy
History
(Medicine ) NONE NONE
藥物過敏
史
X - PCOS-polycystic ovary syndrome / 多囊性卵巢症候群
X- Endometriosis / 子宮內膜異位症
□ PID-pelvic inflammatory disease / 骨盆腔發炎
□ Teratozoospermia / 精子畸型症
Disease □ Endometrial polyp (surgery done already) / 子宮內膜瘜肉
□ Asthenozoospermia /精子無力症
history (已經手術過)
□ Others (please describe it) /其他請在此載記：
疾病史 □Endometrial polyp (without surgery) / 子宮內膜瘜肉 (尚
________________________________________
未手術過)
□ Others (please describe it) /其他請在此載記：
_________________________________
Hormone test 賀爾蒙檢查 Semen analysis 精液檢查
If you have previous report, please scan it send to us
若您有之前的檢查報告，請掃描後寄給我們。
Test result
 AMH:___________________________________
相關檢查
 LH:_____________________________________
數值
 E2:______________________________________
 Prolactin:________________________________
 FSH:_____________________________________
You can describe your condition here.
您可在此描述您的不孕症簡史
1. You have married for 10 years.
2. You have tried to have children for 7 years.
3. Any experience of Intrauterine insemination (IUI) : NO ______________
4. Any experience of In vitro fertilization (IVF) : NO
Other relevant information you would like to share here:

I got pregnant last 2008 and delivered my child on September 27, 20009(9:00am). Unfortunately, he
Infertility died due to Sepsis on the following day ( September 29, 2009/1am).
summary
不孕症簡 We tried to have another baby and seek
史描述
consultations to some OB gyne, but no luck.
Until we met Dra. Gilda Martinez. My
husband and I undergone series of test. I
also had my laparoscopy for endometriosis.
And She ask me to do IVF because of my
health condition and my age. She highly
recommend to do it in you hospital. Praying
and looking forward to be part of your
miracles. Thank you very much.