New couple template

[Patient name] Sarah Jones, 32, Teacher, works in a primary school. Followed by [Partner name] David Smith, 35, Architect, works for a large firm. **AMH levels** 1.2 ng/mL [Reason for patient visit, e.g., primary infertility/secondary infertility] Primary infertility [Previous fertility treatment details, location, and doctor] None [General medical diagnosis relevant to infertility or obstetrics] None Past Medical History: Nil significant Past Surgical History: Appendectomy at age 10 Mental Health History: No history of mental health issues Family History: Mother with early menopause Medications: Folic acid 400mcg daily Past Obstetric and Gynaecology History: G: 0 P: 0 [Pregnancy outcomes and complications] N/A Menstrual Cycles: Regular, 28-day cycle, 5 days of bleeding HMB: No Dysmenorrhoea/Dyspareunia/Dyschezia: Mild dysmenorrhoea PID/STI: No history CST: 2022, normal Contraception: Previously used combined oral contraceptive pill, stopped 6 months ago Pelvic Ultrasound: Normal uterus and ovaries, AFC 10 Social History: Home with [Who patient lives with] Partner Work: Teacher Smoking: Non-smoker ETOH: Occasional social drinking Weight: 65 kg Height: 165 cm BMI: 23.9 Ix: Female screening bloods, pelvic US completed. Partner: Partner: David Smith, 35, present Healthy: No known medical conditions Past Medical History: Nil significant Past Surgical History: Nil significant Mental Health History: No history of mental health issues Family History: Nil significant Medications: Nil Previous Pregnancies: None Non-smoker ETOH: Occasional social drinking No sexual dysfunction No mumps/trauma to testes MSB: Normal SA: Normal Karyotype: Not discussed Expanded GCS: Not discussed [Partner investigations discussed] Semen analysis discussed and planned. Discussion: Discussed the results of the initial investigations. Explained the implications of the AMH level and the importance of further investigations, including a semen analysis for the partner. Discussed lifestyle factors and the importance of a healthy weight and diet. Discussed the possibility of ovulation induction and IUI. [#] Genetic carrier screening and costing discussed [#] Options discussed: Ovulation induction, IUI, IVF. Benefits, risks, and success rates of each discussed. Plan: Arrange semen analysis for partner. Review results in 2 weeks. Discuss further treatment options based on results. Follow-up appointment scheduled for 15 November 2024.