信凯尔-美国专家智能预约平台

Questionnaire

病人资料/Patient information

基础资料/Personal Profile

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

您的身高/厘米/Height / cm

体重千克/Weight / kg

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

试管患者地址/Address
请详细填写目前居住地址，城市，国家/

试管患者微信账号/WeChat ID

试管患者护照号码/Passport number

是否有异性伴侣 - F/Do you have a heterosexual partner?

A.有，我有异性伴侣/Yes, I have a partner B.没有，我是单身/No, I'm single C.没有，我的伴侣是同性/No, I'm homosexual

紧急联系人姓名 - 试管/Emergency Contact Name - IVF

与试管患者的关系 - 试管/Relationship - IVF
如为患者本人，则填“本人”/

紧急联系人电话 - 试管/Emergency Contact - Telephone - IVF

紧急联系人电子邮箱 - 试管/Emergency Contact - Email - IVF

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

你有任何疾病吗？/Do you have any medical problems?
例如：高血压，糖尿病等。如没有，则填“无”/

曾经做过手术吗？/Have you had any surgeries?

A.是/Yes B.否/No

你对麻药会产生不良反应吗?/Did you have any anesthesia problems?

A.是/Yes B.否/No

过敏史详述（填写时请勿空格，请勿分段落）- 试管/Allergies description - IVF
包括过敏原名称_____, 过敏症状_____, 没有可填无/

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

您尝试怀孕多久了？ *例如: 10 个月、4 年, 等。/How long have you been trying to get pregnant? *For example: 10 months, 4 years, etc.

您上一次月经的第一天是什么时候？/When was the first day of your last period?

月经周期状况（可多选）/Menstrual cycle pattern (select all that apply):

A.规律/Regular periods B.量多/Heavy periods C.不规律/Irregular periods D.量少/Light periods E.经期前点状出血/Spotting before periods F.经间出血/Bleeding between periods G.没有月经/No periods

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?

您有被告知您有多囊卵巢综合征 (PCOS)吗？/Have you been told that you have polycystic ovary syndrome (PCOS)?

A.是/Yes B.否/No

您有没有过异常的子宫颈涂片？/Have you ever had an abnormal pap smear?

A.是/Yes B.否/No

您的子宫有子宫肌瘤、息肉或其他问题吗？/Do you have fibroids, polyps or any problems with your uterus?

A.是/Yes B.否/No

如果“是”，请列出子宫肌瘤、息肉或其他问题/ If "YES", please list any conditions affecting the uterus

您是否曾在子宫颈上做过活检、冷冻程序或手术/Have you ever had a biopsy, freezing procedure or surgery on your cervix?

A.是/Yes B.否/No

您子宫或者输卵管是否感染过？/Have you ever had an infection in your uterus or tubes?

A.是/Yes B.否/No

如您子宫或输卵管感染过，治疗时是否使用过抗生素？/If YES，did your uterus or tubes requiring antibiotics?

A.是/Yes B.否/No

您是否做过输卵管照影？/Have you had an HSG (x-ray of the tubes)?

A.是/Yes B.否/No

输卵管照影的结果是什么？是否正常？/ What were the results of the HSG?Are they normal?

A.是/Yes B.否/No

请描述输卵管造影异常现象（填写时请勿空格，请勿分段落）/Please describe the abnormalities of HSG (Do not space out and break into paragraphs when describing)

您曾经做过腹腔镜手术吗？/Have you ever had a laparoscopy surgery?

A.是/Yes B.否/No

腹腔镜手术的结果是什么？是否正常？/What were the results of the laparoscopy?

A.是/Yes B.否/No

请描述腹腔镜手术异常现象（填写时请勿空格，请勿分段落）/Please describe the abnormalities of Laparoscopic surgery (Do not space out and break into paragraphs when describing)

您是否被诊断患有子宫内膜异位症？/Have you been diagnosed with endometriosis?

A.是/Yes B.否/No

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”/

您的雌二醇（E2）检查结果是什么？/What was the result of your Estradiol (E2) test?
如果没有数值，请填“无”/

您的窦卵泡数（AFC）检查结果是什么？/What was the result of your Antral Follicle Counts (AFC)?
如果没有数值，请填“无”/

您曾经做过不育检查吗？如果有，请详细列出（填写时请勿空格，请勿分段落）/Have you had any other fertility testing? (Do not space out and break into paragraphs when describing)。
如没有请填写无/

如果您以前做过不育症治疗, 请选择：（可多选）/ If you have had any infertility treatment(s) in the past, please check all that apply.

A.克罗米芬或者费隆/Clomid or Femara B.(IUI) 子宫内受精/Intrauterine insemination (IUI) C.打促排针的子宫内受精/Fertility injections and IUI D.(IVF) 体外受精/In Vitro Fertilization (IVF) E.没有做过上述任何一项/None of the above F.其他/Other

（可多选）你使用过哪些避孕方案？/What forms of birth control have you used in the past? (Check that all apply)

A.避孕药/Pill B.避孕膜/Patch C.避孕环/Vaginal Ring D.避孕套/Condoms E.体外排精/Withdrawal F.安全期/Rhythm G.其他/Other

您之前一共怀孕多少次？/ How many times have you been pregnant?

A.我从来没有怀过孕。/ I’ve never been pregnant B.一次/1 C.两次/2 D.三次/3 E.四次或更多/4 or more

您之前成功生过多少个小孩？/How many live births？

A.0/0 B.1/1 C.2/2 D.3个及以上/3 & more

女性倾向问试管专家的问题（可多选）/IVF Questions - Female

A.我的试管流程和时间表是什么？/What is IVF process and timeline? B.根据AFC，我有多大可能生下小孩？/Based on AFC, how likely will I have a live birth? C.以我的年龄和目前的状况，能取到多少颗卵子？/How many egg will be retrived give my aged and current condition? D.我会有几个胚胎？/How many embryos will I have? E.我会移植几个胚胎？/How many embryos will be transferred? F.PGS/PGT是什么？/What is PGS/PGT? G.能给我做打针的培训吗？/Will I be given injection training? H.取卵后多久可以移植胚胎？/How long after retreval can transfer occur? I.如果第一周期失败，多久后可以重新开始？/How long can I have another FET if failed on 1st try? J.做试管对身体的副作用？/What are the side effects of IVF?

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

精液分析结果如何？/What were the results of the semen analysis?

A.正常/Normal B.不正常/Abnormal

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

你之前有过几个子女？/How many children do you have before?

A.1/1 B.2/2 C.3个及以上/3 & more

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

您勃起有困难吗？/ Do you have trouble getting an erection?

A.是/Yes B.否/No

您射精有困难吗？/ Do you have trouble ejaculating?

A.是/Yes B.否/No

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

男性倾向问试管专家的问题（可多选）/IVF Questions - Male

A.我需要做哪些身体准备？/What kinds of supplement should I take?？ B.我需要遵循哪些禁忌？/Are there any restrictions that I need to follow? C.你们提供卵妹和代母吗？/Do you provide egg donor and surrogate? D.费用？/Fees? E.项目流程和时间？/Process timeline?

IVF-女性检查报告/IVF-Medical Records - Female

试管超声 - 女性/IVF Ultrasound - F

试管超声日期/Date of IVF Ultrasound

超声类型 - 试管/Type of Ultrasound

A.彩色多普勒超声/Color Doppler Ultrasound B.经阴道超声/Transvaginal Ultrasound

子宫位置/Uterus Position

A.前倾/Anteverted B.后倾/Retroverted

子宫大小/Size of uterus

子宫肌层回声/Myometrial echogenicity

A.均匀/Homogeneous B.不均匀/Heterogeneous

子宫内膜厚度/mm/Endometrium thickness/mm

右侧卵巢大小、窦卵泡计数、最小及最大窦卵泡尺寸（填写时请勿空格，请勿分段落）/Right Ovary Size / AFC /Smallest & Largest size (Do not space out and break into paragraphs when describing)

左侧卵巢大小、窦卵泡计数、最小及最大窦卵泡尺寸（填写时请勿空格，请勿分段落）/Left Ovary Size / AFC /Smallest & Largest size

超声异常/Abnormalities

A.子宫内膜异位/Endometriosis B.子宫肌瘤/Uterine myomas C.子宫息肉/Polyps D.卵巢囊肿/Ovary Cysts E.多囊卵巢综合征/Polycystic disease F.左侧输卵管阻塞/Fallopian Tube Obstruction: Left G.右侧输卵管阻塞/Fallopian Tube Obstruction: Right H.其他/Other G.没有异常/None of the above

其他异常详述（填写时请勿空格，请勿分段落）/Other abnormalities (Do not space out and break into paragraphs when describing)

点击上传超声报告单/Click to upload Ultrasound Report

试管激素六项检测 - 女性/IVF Lab

激素六项检测日期-女性/Date of Fertility Hormone Test

抗缪勒氏管激素 (AMH) (ng/mL)/Anti-Mullerian Hormone (AMH) (ng/mL)
请填写数字，如无则填写无/

雌二醇E2 (pg/mL)/Estradiol(E2) (pg/mL)
请填写数字，如无则填写无/

促卵泡激素 FSH ____(mIU/mL)/Follicle stimulating hormone (FSH) (mIU/mL)
请填写数字，如无则填写无/

睾酮(T) ____(ng/mL)/Testosterone (T) (ng/mL)
请填写数字，如无则填写无/

孕酮 (P) ____(ng/mL)/Progesterone (P) (ng/mL)
请填写数字，如无则填写无/

垂体泌乳素 (PRL) ____(ng/mL)/Prolactin (PRL) (ng/mL)
请填写数字，如无则填写无/

促黄体生成素 (LH) ____(mIU/mL)/Luteunizing hormone (LH) (mIU/mL)
请填写数字，如无则填写无/

点击上传激素六项报告单/Click to upload Fertility Hormone Test Report

血常规-CBC（女性IVF患者填写）/CBC Trend for IVF female

CBC检测日期（IVF - female）/Date of CBC Lab （IVF - female）

HGB/HGB

RBC/RBC

WBC/WBC

NEUT/NEUT

EOS/EOS

PLT/PLT

HbA1C/HbA1C

其他 - 血常规 (CBC) - 女性/Other - CBC - Female
如无则填写无/

点击上传血常规（CBC）报告 - 女性/Click to upload CBC report - Female

传染病组合-女性/Infectious Disease Panel for female

传染病组合检测日期-女性/Date of Infectious Disease Panel

乙型肝炎表面抗原 HBsAg (IU/ml)/HBsAg (IU/ml)
请填写数字，如无则填写None/

乙型肝炎表面抗体 HBsAb (s/co)/HBsAb (s/co)
请填写数字，如无则填写None/

乙型肝炎e抗原测定 HBeAg (PEIU/ml)/HBeAg (PEIU/ml
请填写数字，如无则填写 None/

乙型肝炎e抗体测定 HBeAb (PEIU/ml)/HBeAb (PEIU/ml)
请填写数字，如无则填写None/

乙型肝炎核心总抗体 HBcAb (PEIU/ml)/HBcAb (PEIU/ml)
请填写数字，如无则填写None/

丙型肝炎抗体测定 Anti-HCV (s/co)/Anti-HCV (s/co)
请填写数字，如无则填写None/

艾滋病毒抗体/P24抗原检测 Anti-HIV/P24 (s/co)/Anti-HIV/P24 (s/co)
请填写数字，如无则填写None/

梅毒特异性抗体检测 Anti-TP (s/co)/Anti-TP (s/co)
请填写数字，如无则填写None/

其他-传染病组合/Other-Infectious Disease Panel
如无则填写None/

点击上传传染病组合报告单 - 女性/Click to upload Infectious Disease Panel Report - Female

甲状腺功能-女性/Thyroid Funtions for female

甲状腺功能检测日期-女性/Date of Thyroid Functions Test

总T3 (ng/ml)/T3 (ng/ml)
请填写数字，如无则填写None/

游离 FT3 (pg/mL)/FT3 (pg/mL)
请填写数字，如无则填写None/

总T4 (ug/dL)/T4 (ug/dL)
请填写数字，如无则填写None/

游离 FT4 (ng/dL)/FT4 (ng/dL)
请填写数字，如无则填写None/

促甲状腺素 TSH (uIU/mL)/TSH (uIU/mL)
请填写数字，如无则填写None/

其他甲状腺功能报告/Other Thyroid Functions Level
请填写数字，如无则填写None/

点击上传甲状腺功能（女性）的原始报告/Click to upload the original thyroid functions for female records

其他-女性/Others - female

新冠病毒检测日期-（女性）/COVID-19 testing date - F

新冠病毒检测结果 - (女性）/COVID-19 test result - F

A.阴性/Negative B.阳性/Positive

血型- (女性）/Blood Type - F

A.A/A B.B/B C.AB /AB D.O/O E.其他/Other

RH阳性血型- (女性）/RHD Type - F

A.阴性/Negative B.阳性/Positive

尿液分析检测日期- (女性）/Date of Urinalysis - F

尿液分析检测情况- (女性）/Urinalysis - F

A.正常/Normal B.不正常/Abnormal

粪便分析日期- (女性）/Date of Stool Analysis - F

粪便分析情况- (女性）/Stool Analysis - F

A.正常/Normal B.不正常/Abnormal

IVF-男性检查报告/IVF-Medical Records - Male

精液分析 - 男性/Semen Analysis

精液分析检测日期/Semen Analysis Date

采精方式/Collection Method

A.自慰/Masturbation B.其他/Other

禁欲天数/Days of Abstinence

精液颜色/Color of Semen

A.Clear/清澈透明 B.White/gray/白色或灰色 C.Yellow/黄色 D.Others/其他颜色

精液PH值/PH of Semen

精液体积有多少毫升（mL）？/Semen Volume (mL)
请填写数字，如无则填写None/

精液浓度（百万每毫升）/Sperm Concentration (Million)
请填写数字，如无则填写None/

精液总数（百万/Total Sperm Count (Million)
请填写数字，如无则填写None/

精子活力百分比（%）/Motility (%)
请填写数字，如无则填写None/

点击下方按钮上传您的精液分析报告/Clink on the link below to upload Semen Analysis report (PDF format)
如无可不上传/

血常规-CBC（男性IVF患者填写）/CBC Trend for male

CBC检测日期（IVF - male）/Date of CBC Lab （IVF - male）

HGB/HGB
请填写数字，如无则填写None/

RBC/RBC
请填写数字，如无则填写None/

WBC/WBC
请填写数字，如无则填写None/

NEUT/NEUT
请填写数字，如无则填写None/

EOS/EOS
请填写数字，如无则填写None/

PLT/PLT
请填写数字，如无则填写None/

HbA1C/HbA1C
请填写数字，如无则填写None/

其他 - 血常规 (CBC) - 男性/Other - CBC - Male
如无则填写无/

点击上传血常规（CBC）报告 - 男性/Click to upload CBC report - Male

传染病组合-男性/Infectious Disease Panel for male

传染病组合检测日期-男性/Date of Infectious Disease Panel

乙型肝炎表面抗原 HBsAg (IU/ml)/HBsAg (IU/ml)
请填写数字，如无则填写None/

乙型肝炎表面抗体 HBsAb (s/co)/HBsAb (s/co)
请填写数字，如无则填写None/

乙型肝炎e抗原测定 HBeAg (PEIU/ml)/HBeAg (PEIU/ml
请填写数字，如无则填写None/

乙型肝炎e抗体测定 HBeAb (PEIU/ml)/HBeAb (PEIU/ml)
请填写数字，如无则填写None/

乙型肝炎核心总抗体 HBcAb (PEIU/ml)/HBcAb (PEIU/ml)
请填写数字，如无则填写None/

丙型肝炎抗体测定 Anti-HCV (s/co)/Anti-HCV (s/co)
请填写数字，如无则填写None/

艾滋病毒抗体/P24抗原检测 Anti-HIV/P24 (s/co)/Anti-HIV/P24 (s/co)
请填写数字，如无则填写None/

梅毒特异性抗体检测 Anti-TP (s/co)/Anti-TP (s/co)
请填写数字，如无则填写None/

其他-传染病组合/Other-Infectious Disease Panel
如无则填写None/

点击上传传染病组合报告单 - 男性/Click to upload infectious Disease Panel Report - Male

其他-男性/Others - male

新冠病毒检测日期 -（男性）/COVID-19 testing date - M

新冠病毒检测结果 -（男性）/COVID-19 test result - M

A.阴性/Negative B.阳性/Positive

血型 -（男性）/Blood Type - M

A.A/A B.B/B C.AB/AB D.O/O E.其他/Other

RHD 类型 -（男性）/RHD Type - M
如果你是熊猫血，则选A，其他选B/

A.阴性/Negative B.阳性/Positive

PSA检测日期与结果 -（男性）/PSA testing date and result - M
如无则填写无/

尿液分析检测日期 -（男性）/Date of Urinalysis - M

尿液分析检测情况 -（男性）/Urinalysis - M

A.正常/Normal B.不正常/Abnormal

粪便分析日期 -（男性）/Date of Stool Analysis - M

粪便分析情况 -（男性）/Stool Analysis - M

A.正常/Normal B.不正常/Abnormal

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，请直接提交。双阴检测的客人，检测机构要求务必填写信用卡信息，否则不接受预约。/

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/Insurance card: Front

请拍下您的保险卡背面照片/Insurance card: Back

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