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Reproductive Medicine, Box 223 Cambridge University Hospitals NHS Foundation Trust Referral Proforma: Suspected infertility All investigations should be within 3 months of date of referral Incomplete proformas may not be processed Please enclose copies of all investigations, if performed out of Addenbrooke’s area This is an: NHS Referral Self-funding Referral Refer via Choose and Book or to: Reproductive Medicine, Box 223 Hills Road, Cambridge CB2 0QQ Refer to Cambridge IVF, Box 123 Hills Road, Cambridge CB2 0QQ Tel: 01223 216227 Fax: 01223 586591 Tel: 01223 349010 Fax: 01223 726373 I am sending an accompanying letter ________________________________________________________________________________________________________________________________________________________________________ Referring GP's details for FEMALE patient (please print or stamp): Name: Sender name......................................... Surgery address: Sender organisation name Surgery Fax: Sender fax ................................... Sender address ....................................................... Referral date: Referral date .............................. Please refer women who have been trying to become pregnant: for more than two years if aged under 35 years for more than one year if aged over 35 years unless the cause is 'obvious' (i.e. irregular cycles, history of PID, suboptimal semen analysis) History of infertility as a couple: Primary Secondary ......................................................................................................................................................... (duration) Comments: ..................................................................................................................................................... ........................................................................................................................................................................ FEMALE patient's details: Surname: Surname......................................... NHS No: NHS number ............................................. Forename: Forename ..................................... Hosp No: ................................................................. Age: Patient Age ............................................. Date of birth: Date of birth ........................................ Address: Patient address - single line ............ Home Tel: Patient home telephone number ............ Alternate Tel: Patient alternate telephone number Mobile Tel: Patient mobile telephone number Language of choice: ................................................ Communication/understanding difficulties ..................................................................................................................................................... Page 1 of 3 Date: 05/04/2012 Version 2 File: in correspondence section of Medical Records Three-page form Reproductive Medicine, Box 223 Cambridge University Hospitals NHS Foundation Trust Female patient's name: Forename Surname Date of birth: Date of birth ________________________________________________________________________________________________________________________________________________________________________ Male partner details: If there is a male partner, please ensure his details including GP contact details are completed (see last page of this form) and sent with this proforma. Details of a male partner are not required for this referred woman FEMALE patient: (please attach copies of all results) Female patient's name: Forename Surname .......................... Date of birth: Date of birth ............................. Parity: ....................................................................................................................................................... ...... Body Mass Index: ................... History of PID Date: .............................. Endometriosis If BMI is greater than 30, advise weight loss Fibroids Folic acid therapy started Surgery etc to cervix: ........................................................................................................................................................................ Rubella status: Rubella immune Vaccination arranged Normal Abnormal Date: ............................... Cervical smear: Date: ............................... Chlamydia swab (endocervical/urethral): Normal Abnormal Normal Abnormal Date: ............................... High vaginal swab (HVS) (for vaginal infections): Date: ............................... Serum progesterone (mid luteal 7 days before next expected period): ……………..nmol/L Day 2-7: LH ……………….........IU/L FSH ……………………..IU/L Date: ………………......... Date: ………………......... Only if progesterone is abnormal or patient is oligo/amenorrheic: Testosterone: ................................. nmol/L Prolactin: ........................ mU/L TSH: .......................... mU/L Date ......................................... Current medication: ......................................................................................................................................... ......................................................................................................................................................................... Comments: ...................................................................................................................................................... ......................................................................................................................................................................... ......................................................................................................................................................................... Page 2 of 3 Date: 05/04/2012 Version 2 File: in correspondence section of Medical Records Three-page form Reproductive Medicine, Box 223 Cambridge University Hospitals NHS Foundation Trust Female patient's name: Forename Surname Date of birth: Date of birth ___________________________________________________________________________________ MALE partner's details: Surname: ................................................................. NHS No: .................................................................. Forename: ............................................................... Hosp No: .................................................................. Date of birth: ............................................................ Age: ......................................................................... Address: .......................................................................................................................................................... Home Tel: ................................................................ Work Tel: ................................................................. Mobile Tel: ............................................................... Language of choice: ................................................ Communication/understanding difficulties ........................................................................................................................................................................ ___________________________________________________________________________ Referring GP's details for MALE partner (please print or stamp): Name: ............................................................................................................................................................. Surgery address: ............................................................................................................................................ Referral date: ........................................................... Surgery Fax: ............................................................ ____________________________________________________________________________________ MALE partner (please attach copies of all results): Seminal fluid analysis: Date of analysis .............................................................................................................................................. Number sperm: .................................... /ml % motility:.......................... % % normal: ......................... % ............................................................................................................... (If abnormal, repeat after six weeks) Past medical history: ........................................................................................................................................ ......................................................................................................................................................................... ......................................................................................................................................................................... Clinical findings: ............................................................................................................................................... ......................................................................................................................................................................... Current medications: ........................................................................................................................................ ......................................................................................................................................................................... ..................................................................................................................................................... ____________________________________________________________________________________ Notes: please ensure that where there is a male partner all details are attached to the female partner's information and sent to us together. Page 3 of 3 Date: 05/04/2012 Version 2 File: in correspondence section of Medical Records Three-page form