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Please fill in the below fields carefully and accurately, as the doctor's advice will be based on the the information you submit here.
Basic Information
female
Male/Partner
Health History
health history
Female Partner

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Male Partner

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Family History
Are there any medical or genetic conditions in your family? Please provide details:
Social History
Female Partner
Male Partner
Menstrual History (Female)
Menstrual History (Female)
Are your periods regular?
Are are your periods painful?
Please select last three months period dates (Start to End)
Fertility History
Fertility history for current relationship
Please describe in full detail
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