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FERTILITY UNIT REFERRAL FORM

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					                                         FERTILITY UNIT REFERRAL FORM
                                       To be completed by GP or practice nurse

We advise at least 2-3 months BEFORE a referral is made, that the following factsheets are given to
the couple:-
 ‘Information from the Fertility Clinic’   Date given to couple =
 ‘Timing intercourse for the fertile time’ Date given to couple =
With this information a very good proportion of couples conceive thus never need referral!

   Please refer to Subfertility – Quick Reference Guide for Primary Care
   All information is available at nww.pbh-tr.nhs.uk (follow links Other GP Referral Forms - Fertility Service)
   Any queries please ring the Clinical Nurse Specialists: Sister Fiona Wynn or Sis ter Wendy Eustace on 01733 673750 (voicemail) or
    01733 678000 bleep 1032
On completion of this form please send electronically via Choose and Book or fax to Call Centre on 01733 678526

              Female Partner                                                             Male Partner
Surname:                                                       Surname:
Forename:                                                      Forename:
Age:               Date of Birth:                              Age:                         Date of Birth:
Interpreter? Yes ‫ڤ‬           No                  ‫ڤ‬             Interpreter? Yes           ‫ڤ‬          No ‫ڤ‬
Language?                                                      Language?
Address:                                                       Address:




Telephone:                                                     Telephone:
Mobile:                                                        Mobile:
NHS number:                                                    NHS number:
Hospital number:                                               Hospital number:
GP details:                                                    GP details:




Referral date:                                                 Referral date:
Length of subfertility:
                     History                                                                History
Past medical history:                                          Past medical history:
Nil ‫ڤ‬                                                          Nil ‫ڤ‬
Details:                                                       Details:


Present medication:                                            Present medication:


Previous Chlamydia/STIs?                                       Previous Chlamydia/STIs?
Nil ‫ڤ‬                                                          Nil ‫ڤ‬
Details:                                                       Details:
Past Gynae history:                                            Previous urology/genital history:
Nil ‫ڤ‬                                                          Nil ‫ڤ‬
sliateD                                                        sliateD

Menstrual Cycle:
Amenorrhoea:                    ‫ڤ‬
Between 25-42 days              ‫ڤ‬
(normal):
42 days:                       ‫ڤ‬
Peterborough Fertility Unit Referral Form. Sr Fiona Wynn. Version 03.11. Review 03.13
Past Obstetric History:
Nil ‫ڤ‬
sliateD
                                    Examination and Results
Weight:
BMI:
Date recorded:
Pelvic examination:                           Genital examination:
Normal ‫ڤ‬               Abnormal         ‫ڤ‬     Normal ‫ڤ‬                                      Abnormal         ‫ڤ‬
Pelvic/Abdo scan results (if done)
Normal ‫ڤ‬               Abnormal         ‫ڤ‬
Investigations:                               Investigations:
Rubella immune ‫ڤ‬             not immune ‫ڤ‬     1st semen analysis
                             date:            Date:

Chlamydia not detected ‫ ڤ‬detected                     ‫ڤ‬
                         date:

Progesterone result:                 date:
(Ideally 7 days before predicted period. If irregular
cycles give forms for days 21, 28 and 35 of cycle)



Baseline hormones (if done): Only accurate if                  Please attach copy of result if not done at Peterborough
carried out on day 1, 2 or 3 of the cycle or anytime if no     Hospital.
cycles (can be done after day 42 if very long cycle).
Only carry out if irregular cycles or amenorrhoea.
                                                               If necessary a 2nd S/A can be arranged by the
Baseline hormones and progesterone have to be done             Fertility Clinic, (must be at least 3 months after 1st
at different times in the cycle. No point in doing these       test).
together.




FSH ………LH ….…..… Estradiol ..........

Testosterone ………… TSH …………....

Prolactin: ………….               date:



   For reference ranges of all results please go to
    nww.pbh-tr.nhs.uk (follow links Other GP Referral Forms
    - Fertility Servic e)


Additional information;




Peterborough Fertility Unit Referral Form. Sr Fiona Wynn. Version 03.11. Review 03.13

				
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