信凯尔-美国专家智能预约平台

病人资料/Patient Information

基础资料/Personal Profile

是否有美国医院接受的医院保险/Do you have insurance accepted by the US healthcare providers?

A.是/Yes B.否/No C.不知道/Don't know

是否要选择医院所在地区（本题可多选）：/Prefer region

A.东部（纽约波士顿）/East (New York, Boston) B.旧金山/San Francisco C.洛杉矶/Los Angeles D.无要求/No preference E.如已有胚胎，请在下一题填写胚胎所在诊所以及医生信息/If embryos were made, please indicate where embryos are currently stored and attending IVF physician information.

指定医院，医生或诊所 - 试管 /Prefer hospital, provider or clinic - IVF

期望预约咨询的时间/Choose preferred appointment time frame

A.1-4 周内/Within 1-4 weeks B.4-8 周内/Within 4-8 weeks C.8周以上/More than 8 weeks D.没有偏好/No preference

是否具有来美签证/Do you have US visa

A.是/Yes B.否/No

是否需要医院邀请函/Whether need invitation from provider for visa

A.是/Yes B.否/No

是否需要翻译？/Do you need an interpreter?

A.是/Yes B.否/No

从哪里了解到信凯尔 - 其他/How did you hear about Sincare?

你的留言（填写时请勿空格，请勿分段落）/Your messages (Do not space out and break into paragraphs when describing)

IVF 基础问卷/IVF Intake

IVF 周期基础咨询/IVF Consultation

试管咨询目的：可复选/Purpose of IVF Consultation: Choose all that apply

A.美国自精自卵试管/IVF with own egg and sperm B.美国借精试管/IVF with donor sperm C.美国借卵试管/IVF with donor egg D.美国卵子冷冻/Egg freezing E.美国第三方辅助生殖_已有胚胎/Surrogacy F.美国因健康原因需要第三方辅助生殖/Surrogacy due to personal health issue G.美国因非身体健康原因需要第三方辅助生殖/Surrogacy due to non-personal health issue H.美国借卵代孕/Surrogacy with donor egg I.美国借精代孕/Surrogacy with donor sperm

请描述因何身体原因需要代孕。（填写时请勿空格，请勿分段落）/Please describe personal health issue (Do not space out and break into paragraphs when describing)

试管患者姓名/Name
请按照护照上显示，用英文拼音填写，名在前，姓在后。如张三为“San Zhang”/

试管患者生日/Date of Birth

试管患者性别/Gender
如果夫妻做试管（包括借卵借精代孕），以女方为患者填写。/If patient has partner, fill in female patient information.

A.男/Male B.女/Female

试管患者电话/Telephone
请用划线“-”对号码进行分隔，如：000-000-0000 或是 +86 13600000000/

试管患者邮箱/Email

试管患者微信账号/WeChat ID

你能够提供哪些女性检查报告（本题可多选）/Available Female Medical Records (Choose all that apply)

A.B超/Ultrasound B.生殖激素六项/Hormones C.血常规/CBC D.传染病组合/Infectious Disease E.甲状腺功能/Thyroid Function F.其他/Other Test Result G.没有可提供的检查报告/None

你能够提供哪些男性检查报告（本题可多选）/Available Male Medical Records (Choose all that apply)

A.精液分析/Semen Analysis B.血常规（CBC）/CBC C.传染病组合/Infectious Disease D.其他/Other Test Result E.没有可提供的检查报告/None

列出正在服用的处方药的药名及功效 IVF（填写时请勿空格，请勿分段落）/Mediation List (Do not space out and break into paragraphs shen describing).
请填写：药名____功效____ 剂量____ 如何服用____,没有则不填。例：服用硝苯地平—用于降血压/

IVF 周期前女性病史/IVF Intake - Female

您下一次月经的第一天是什么时候？/When will be the first day of your next period?

你一般月经来___天/During your period, how many days do you bleed?
请填写数字/

月经之间通常间隔的天数是多少？/What is the usual number of days between periods?

您的卵泡生成激素（FSH）检查结果是什么？/What was the result of your Follicle Stimulating Hormone (FSH) test?
如果没有或不知道，则填“无”/If never tested or don't know, please enter "none".

您的血清抗苗勒管激素(AMH) 检查结果是什么？/What was the result of your Anti-Mullerian Hormone (AMH) test?
如果没有或不知道，则填“无”/If never tested or don't know, please enter "none".

IVF 周期前男性病史/IVF Intake - Male

你之前做过精液分析检查吗？/Have you had a semen analysis in the past?

A.是/Yes B.否/No

您是否曾经与另外的伴侣有过小孩？/Have you ever produced a child with another partner?

A.是/Yes B.否/No

您有做过其他的生育方面的检查吗？/Have you had any other fertility testing done in the past?

A.是/Yes B.否/No

之前的生育检查结果如何？/What is the result of prior fertility test?

A.正常/Normal B.不正常/Abnormal

您之前做过不育症治疗？手术，激素替代疗法，药物，其他/Have you had any infertility treatment in the past?

A.没有/Never B.手术/Surgery C.激素替代疗法/Hormone replacement therapy D.药物/Medication E.其他/Other infertility treatment not listed above

您是否有任何与精子或生育问题有关的病史, 例如:/Do you have any medical history that may relate to a sperm or fertility issue such as:

A.经常泡热水澡或者洗桑拿浴？/Frequent hot baths or saunas B.隐睾睾丸？/Cryptorchid testis C.腹股沟外伤或手术？/Groin trauma or surgery D.精索静脉曲张？/Varicocele E.输精管结扎术？/Vasectomy F.其他/Others not listed above G.没有/None of the above

账单支付信息/Payment Information

支付信息/Payment

选择医疗账单支付方式/Payment Type
如无保险请填信用卡信息以加快预约。若暂时不希望提供信用卡信息，填0。/

A.自付信用卡/Self Pay; Credit Card B.保险支付/Insurance

保险信息/Insurance Information

请拍下您的保险卡正面信息//

请拍下您的保险卡背面照片//