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  • Rumah Sakit Citra Husada: Jl. Dharma Bakti No. 45 C Nanga Pinoh Telp. (0568) 22355 Fax. (0568) 21645 Melawi - Kalbar

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    FilzaFathuloh
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    This document is a form for intrauterine insemination (IUI) using a natural cycle protocol from Rumah Sakit Citra Husada hospital. It includes fields to record information about the patient and their spouse, including their medical history, dates of menstruation and ultrasound results, details of the IUI procedure such as sperm counts and medication administered, and spaces for documenting two IUI attempts. The form is used to standardize the collection of medical data for patients undergoing IUI treatment.

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    Original Title

    Form Inseminasi

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    This document is a form for intrauterine insemination (IUI) using a natural cycle protocol from Rumah Sakit Citra Husada hospital. It includes fields to record information about the patient and their spouse, including their medical history, dates of menstruation and ultrasound results, details of the IUI procedure such as sperm counts and medication administered, and spaces for documenting two IUI attempts. The form is used to standardize the collection of medical data for patients undergoing IUI treatment.

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    © All Rights Reserved
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    6 views1 page

    Rumah Sakit Citra Husada: Jl. Dharma Bakti No. 45 C Nanga Pinoh Telp. (0568) 22355 Fax. (0568) 21645 Melawi - Kalbar

    Uploaded by

    FilzaFathuloh
    This document is a form for intrauterine insemination (IUI) using a natural cycle protocol from Rumah Sakit Citra Husada hospital. It includes fields to record information about the patient and their spouse, including their medical history, dates of menstruation and ultrasound results, details of the IUI procedure such as sperm counts and medication administered, and spaces for documenting two IUI attempts. The form is used to standardize the collection of medical data for patients undergoing IUI treatment.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
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    RUMAH SAKIT CITRA HUSADA

    Jl. Dharma Bakti No. 45 C Nanga Pinoh


    Telp. (0568) 22355 Fax. (0568) 21645
    Email : rscitrahusadangp@gmail.com
    MELAWI KALBAR

    Form Inseminasi Intrauterin (IUI) Protokol Natural Cycle

    No. RM :
    Nama Istri : .. No. HP Istri :
    Nama Suami : .. No. HP Suami :
    Alamat : ..

    Istri
    Tahun :
    Tgl :
    1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
    Haid
    USG Ovarium
    Kanan (mm)

    Jumlah Ukuran
    (diameter)

    Ovarium
    Kanan (mm)

    Jumlah Ukuran
    (diameter)

    Endo Ketebalan (mm)

    Metrium Bentuk

    Stimulasi ..

    Trigger hCG

    Inseminasi Intrauterin

    Suami
    Diagnosis :
    Jumlah sperma pre-washing
    Jumlah sperma pre-washing

    Prosedur Inseminasi Intrauterin


    I II
    Tanggal / / .. / / ..
    Jumlah sperma
    Dokter Pelaksana Tindakan
    Support Fase Luteal
    hCG 5.000 IU Estradiol Valerat 4 mg
    hCG 10.000 IU Estradiol Valerat 8 mg
    Progesteron 400g Progesteron 800g

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