NCP Programme Dashboard - Grace Fertility

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Displaying 1 - 4 of 4

Date Created	Unique ID	Patient's Name	Partner's Name
February 10, 2022
February 9, 2022	6dbbe	Urvashi	Aman Bajaj
January 27, 2022	b927b	Sugandha	Akhil
January 10, 2022	1234567	Tina Tuteja	Ankur Midha
Date Created	Unique ID	Patient's Name	Partner's Name

Displaying 1 - 4 of 4

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New Onboarding

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1Onboarding

2Diagnostics

3Doctor

4Lifestyle Session

5Mental Health Session

6Submit

Add Diagnostics

Yes

Not yet

Add Doctor's consultation

Yes

Not yet

Add Lifestyle Session

Yes

Not yet

Add Mental Health Session

Yes

Not yet

Basic Details

Unique ID

Patient's Name

Coach's Name

Doctor's Name

Date of On-boarding

Hidden

Patient's Name

In full

Patient's Occupation

Patient's DOB

Age

Patient's Location

Partner's Name

In full

Partner's Occupation

Partner's DOB

Partner's Location

Pregnancy History

Pregnancy/M/T History

Have you had any pregnancies

Yes (Including miscarraiges/terminations)

No

No. of pregnancies

Ectopic Pregnancies

Pregnancies >20weeks

Pregnancies <20weeks

No. of elective terminations

Do you have any children?

Yes

No

No. of Children

Have you had any miscarraiges/terminations?

Yes

No

Living children

Delivery	Date of Delivery	Months to conceive	Actions
			Edit Delete
There are no Children.

Maximum number of children reached.

No. of Miscarraiges

No. of Terminations

Miscarraige/Termination history

M/T	Date of M/T	Months to conceive	Weeks of Pregnancy	Actions
				Edit Delete
There are no Entries.

Maximum number of entries reached.

Menstrual History

Date of last period

How often do you have a period? (first day to first day)

How regular are your periods?

Regular

Irregular

Are your periods:

Heavy

Normal

Light

Do you have spotting between periods?

Severe pain with periods?

Yes

No

Sometimes

Always

Medical History

Do you have any medical illnesses?

Yes

No

Please list any and all illnesses:

Do you take any routine medications, including herbal preparations?

Yes

No

Please list any and all medications

Do you have any allergies (Food, medication, etc.)

No

Yes

Please list any allergies (Food, medication, etc.)

Do you have any of the following medical conditions?

Diabetes

High BP

Heart Disease

Depression (F)

Depression (M)

None of the above

Gynaecological History

Have you been diagnosed with any of these conditions?

Uterine Myoma (fibroid)

Endometriosis

Pelvic Adhesions

Tubal Obstructions

Brief history on contraceptive use

Endocrine History

Do you have/had any of the following conditions?

Surgical History

Have you ever undergone surgery?

Yes

No

List all of your pelvic or abdominal surgeries:

Date	Type	Diagnosis	Actions
			Edit Delete
There are no Surgeries.

Maximum number of surgeries reached.

Social History

Do you smoke?

No

Occasionally

Regularly

Chain smoker

Do you drink alcohol?

No

Occasionally

Drinking Frequency

Do you use any recreational drugs?

No

Occasionally

Regularly

Do you exercise?

No

Occasionally

Regularly

Lifestyle History

Meal Timing

Routine

Random

Eating Habits

Lifestyle type

Sedentary

Active

Schedule

Hectic

Relaxed

Unpredictable

Sleep Time

:

Waking time

:

Sleep Hours

Physical Activity

Lifestyle History Summary

Prior Infertility Testing

Have you had any immunology or thrombophilia testing?

Unknown

Yes

No

Have you had any of the following tests? Check all that apply:

X-ray of tubes (HSG)

Antral Follicle Count (AFC)

Sonohysterogram (saline ultrasound)

Hysteroscopy

Laparoscopy

Please upload any relevant test results

Max. file size: 100 MB.

Blood tests, Ultrasounds etc.

Have you seen other doctors for infertility or had infertility treatments?

No

Yes

Briefly describe any infertility treatment and doctors recommendations

Prior Infertility Treatment

Have you had any of the following treatments?

Clomiphene citrate:

No

Yes

# of Clom. C. cycles

Please enter a number from 0 to 99.

Outcome of Clomiphene citrate:

No pregnancy

Pregnant

Miscarraige

Intrauterine Insemination (IUI)

No

Yes

# of IUI cycles

Please enter a number from 0 to 99.

Outcome of IUI:

No pregnancy

Pregnant

Miscarraige

Clomiphene and Insemination

No

Yes

# of C&I cycles

Please enter a number from 0 to 99.

Outcome of C&I:

No pregnancy

Pregnant

Miscarraige

Gonadotropin and insemination

No

Yes

# of G&I cycles

Please enter a number from 0 to 99.

Outcome of G&I:

No pregnancy

Pregnant

Miscarraige

In-vitro Fertilization (IVF)

No

Yes

# of IVF cycles

Please enter a number from 0 to 99.

Outcome of IVF:

No pregnancy

Pregnant

Miscarraige

Frozen Embryo Transfer (FET)

No

Yes

# of FET cycles

Please enter a number from 0 to 99.

Outcome of FET:

No pregnancy

Pregnant

Miscarraige

Have you used donor eggs or donor sperm as part of your treatment?

No

Yes

Quick Print (NCP Plan)

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Member Select

UID

Patient's Name

Coach's Name

Doctor's Name

Date of On-boarding

Patient's Name

In full

Patient's Occupation

Patient's DOB

Age

Partner's Name

In full

Partner's Occupation

Partner's DOB

Age

Pregnancy History

Have you had any pregnancies

Yes (Including miscarraiges/terminations)

No

Pregnancy/M/T History

No. of pregnancies

Ectopic Pregnancies

Pregnancies >20weeks

Pregnancies <20weeks

No. of elective terminations

Do you have any children?

Yes

No

No. of Children

Have you had any miscarraiges/terminations?

Yes

No

Living children

Delivery	Date of Delivery	Months to conceive	Actions
			Edit Delete
There are no Children.

Maximum number of children reached.

No. of Miscarraiges

No. of Terminations

Miscarraige/Termination history

M/T	Date of M/T	Months to conceive	Weeks of Pregnancy	Actions
				Edit Delete
There are no Entries.

Maximum number of entries reached.

Menstrual History

Date of last period

How often do you have a period? (first day to first day)

How regular are your periods?

Regular

Irregular

Are your periods:

Heavy

Normal

Light

Do you have spotting between periods?

Severe pain with periods?

Yes

No

Sometimes

Always

Medical History

Do you have any medical illnesses?

Yes

No

Please list any and all illnesses:

Do you take any routine medications, including herbal preparations?

Yes

No

Please list any and all medications

Do you have any allergies (Food, medication, etc.)

No

Yes

Please list any allergies (Food, medication, etc.)

Do you have any of the following medical conditions?

Diabetes

High BP

Heart Disease

Depression (F)

Depression (M)

None of the above

Gynaecological History

Have you been diagnosed with any of these conditions?

Uterine Myoma (fibroid)

Endometriosis

Pelvic Adhesions

Tubal Obstructions

Brief history on contraceptive use

Endocrine History

Do you have/had any of the following conditions?

Thyroid disease

Hairloss/Thinning

Increased facial or body hair

Inappropriate breast milk production

Acne

Increased Prolactin

Gestational Diabetes

None of the above

Endocrine History

Surgical History

Have you ever undergone surgery?

Yes

No

Surgical summary

List all of your pelvic or abdominal surgeries:

Date	Type	Diagnosis	Actions
			Edit Delete
There are no Surgeries.

Maximum number of surgeries reached.

Social History

Do you smoke?

No

Occasionally

Regularly

Chain smoker

Do you drink alcohol?

No

Occasionally

>2 drinks a day

>5 drinks a day

Drinking frequency

Do you use any recreational drugs?

No

Occasionally

Regularly

Do you exercise?

No

Occasionally

Regularly

Prior Infertility Testing

Have you had any immunology or thrombophilia testing?

Unknown

Yes

No

Have you had any of the following tests? Check all that apply:

X-ray of tubes (HSG)

Antral Follicle Count (AFC)

Sonohysterogram (saline ultrasound)

Hysteroscopy

Laparoscopy

Please upload any relevant test results

Max. file size: 100 MB.

Blood tests, Ultrasounds etc.

Have you seen other doctors for infertility or had infertility treatments?

No

Yes

Briefly describe any infertility treatment and doctors recommendations

Prior Infertility Treatment

Have you had any of the following treatments?

Clomiphene citrate:

No

Yes

# of Clom. C. cycles

Please enter a number from 0 to 99.

Outcome of Clomiphene citrate:

No pregnancy

Pregnant

Miscarraige

Intrauterine Insemination (IUI)

No

Yes

# of IUI cycles

Please enter a number from 0 to 99.

Outcome of IUI:

No pregnancy

Pregnant

Miscarraige

Clomiphene and Insemination

No

Yes

# of C&I cycles

Please enter a number from 0 to 99.

Outcome of C&I:

No pregnancy

Pregnant

Miscarraige

Gonadotropin and insemination

No

Yes

# of G&I cycles

Please enter a number from 0 to 99.

Outcome of G&I:

No pregnancy

Pregnant

Miscarraige

In-vitro Fertilization (IVF)

No

Yes

# of IVF cycles

Please enter a number from 0 to 99.

Outcome of IVF:

No pregnancy

Pregnant

Miscarraige

Frozen Embryo Transfer (FET)

No

Yes

# of FET cycles

Please enter a number from 0 to 99.

Outcome of FET:

No pregnancy

Pregnant

Miscarraige

Have you used donor eggs or donor sperm as part of your treatment?

No

Yes

Lifestyle History

Meal Timing

Routine

Random

Eating Habits

Lifestyle Type

Sedentary

Active

Schedule

Hectic

Relaxed

Unpredictable

Hidden

Sleep

Hidden

Wake

Sleep hours

Physical Activity

Overall Summary

Diagnostics

Patient's Age Group

Partner's Age Group

Patient's Weight(Kg)

Patient's Height (feet)

Patient's BMI

Patient's BMI Range

Hidden

Patient's BMI inference

Partner's Weight(Kg)

Partner's Height (feet)

Partner's BMI

Partner's BMI Range

Hidden

Partner's BMI inference

Female

Her name (Diag)

AMH (Anti-Muellerian Hormone) (ng/ml)

Please enter a number from 0 to 10.

AMH Range (ng/ml)

Hidden

AMH Range (ng/ml)

AFC (Left)

Please enter a number from 0 to 30.

AFC (Right)

Please enter a number from 0 to 30.

AFC (Total)

AFC Range

Hidden

AFC Range

PCOS?

Yes

No

Hidden

PCOS qualify

Yes

No

Hidden

PCOS inference

Yes

No

U.S./Abnormalities Detected

Uterine (Shape/Cavity)

Fibroids

Tubal Blockage

Endometriosis

PCOS

Abnormality/Ultrasound summary (Uterine/Tube abnormalities)

Male

His name (Diag)

Sperm Count (millions/ml)

Sperm count Range

Sperm count Range

Sperm Morphology (%)

Please enter a number from 0 to 100.

Sperm morphology Range

Hidden

Sperm morphology Range

Sperm motility (%)

Please enter a number from 0 to 100.

Sperm motility Range

Sperm motility Range

Additional

Idiopathic infertility?

Yes

No

Further testing required

Hidden

K Factor

Hidden

Fertility Score

Doctor's Consultation

Name of Patient (Prescription)

Date of Consultation

Purpose/Concern

Age (Prescription)

Summary of Doctor's Consultation

Sl

Medication Name

Dosage

Frequency

Total Duration

Spl. Instructions

Recommended Lab tests & Referrals

Follow-up Details

Date of sign

Signature

Lifestyle Consultation

Current BMI (F)

Please enter a number from 0 to 50.

Week

Physical Activity(Lifestyle)

Duration/Week

Total Duration(minutes)

Summary of Lifestyle Session

Summary of Nutrition Session

Mental Health Session

Summary of Mental Health Session

Additional fields

Her BMI (ref)

Patient's Location

Partner's location

CC Outcome

IUI Outcome

CandI Outcome

GandI Outcome

IVF Outcome

FET Outcome

BMI Inf(F)

AMH Inf(F)

AFC Inf(F)

PCOS Val(F)

PCOS Inf(F)

BMI Inf(M)

SpermC inf. (M)

SpermM inf. (M)

SpermMor inf. (M)

Sleep Time

:

Waking time

:

PDF Plan finalization

Doctor's Signature

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