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Questionnaire
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 US Health Care Providers
A.是/Yes
B.否/No
C.不知道/I 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）/Eastern US (NY Boston)
B.旧金山硅谷/San Francisco
C.洛杉矶/Los Angeles
D.无要求/No request
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 embryo is created, please list name of the fertility center and doctor's information in the next question.
指定医院，医生或诊所 /Preferred hospital, provider or clinic
如不指定，则填“无”; 如已有胚胎，请填写胚胎所在诊所以及医生信息。/
期望预约远程咨询的时间/Choose preferred appointment time frame
A.1-4 周内/1-4 weeks
B.4-8 周内/4-8 weeks
C.8周以上/8+ weeks
D.没有偏好/No preference
是否需要医院邀请函/Whether need invitation from doctor for visa
A.是/Yes
B.否/No
是否具有来美签证/Do you have US visa
A.是/Yes
B.否/No
是否需要翻译？/Do you need an interpreter?
A.是/Yes
B.否/No
从哪里了解到的信凯尔（本题可多选）/How did you hear about SinCare?
A.华人资讯网/Chinese news
B.YouTube直播/YouTube
C.微信公众号/WeChat Official Account
D.百度搜索/Baidu
E.谷歌Google搜索/Google
F.慈铭/CiMing
G.登机牌广告/Boarding pass
H.其他 - 请在下题中填写/Other - Please specify in the next question
从哪里了解到信凯尔 - 其他/How did you hear about Sincare - Others
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 using donor sperm
C.美国借卵试管/IVF using 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_already have embryos
F.美国因健康原因需要第三方辅助生殖/Surrogacy due to medical reasons
G.美国因非身体健康原因需要第三方辅助生殖/Surrogacy due to non-medical reasons
H.美国借卵代孕/Egg Donation and Surrogacy
I.美国借精代孕/Sperm Donation and Surrogacy
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 the medical reason of needing surrogacy service. (Do not space out and break into paragraphs when describing)
试管患者姓名/Name
请填写英文拼音填写，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。/
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 famale medical records
A.B超/IVF Ultrasound questionnaire
B.生殖激素六项/IVF lab intake
C.血常规 (CBC)/CBC trend
D.传染病组合/Infectious Disease Panel
E.甲状腺功能/Thyroid Funtions
F.其他/Other tests
G.没有可提供的检查报告/No available records
你能够提供哪些男性检查报告（本题可多选）/Available male medical records
A.精液分析/Semen Analysis
B.血常规（CBC）/CBC Trend
C.传染病组合/Infectious Disease Panel
D.其他/Other tests
E.没有可提供的检查报告/No available records
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）/Medication List (Do not space out and break into paragraphs when 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”/
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”/
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?
A.是/Yes
B.否/No
之前的生育检查结果如何？/What were the results of previous fertility testing?
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/Medicine
E.其他/Other
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 tubs or saunas?
B.隐睾睾丸？/Undescended testicle?
C.腹股沟外伤或手术？/Groin injury or surgery?
D.精索静脉曲张？/Varicocele?
E.输精管结扎术？/Vasectomy?
F.其他/Other
G.没有/None of the above
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