Questionary

Female

General information

Given name*
Family name*
Address*
Place
Zip code*
City*
Country*
Identification number/date of birth*
Mobile*
Email*
May we respond to you by mail*
May we send SMS to you*
Marital status*
Your occupation*
Name of practitioning physician
Partners sex*

The woman

General health information

Allergies*
- To what and how are the symptoms
Are you allergic to any medication*
- To which medication and what are the symptoms
Medication*
- Write name, strength, dose, and reason
Herbal medicine*
- Name and dosis
Folic acid*
Tobacco*
- How many cigarettes a day
Alcohol*
- Number of drinks per week
Are you healthy and fit*
Do you suffer from chronic diseases (e.g metabolic disease, diabetes etc.)
Have you ever had any surgery*
reason for surgery, where and when
hereditary diseases*
which diseases
Have you ever had a blood clot*
Have you been taking medication against depression,anxiety or other mental disorder*
for what kind of disorder
Have you attented psychological treatment*
For what reason
Have you been admitted to a psychiatric ward *
- for what reason, where and when
If you have had treatment from a psychologist or psychiatric ward, will you allow us to contact your therapist/former therapist
- who should we contact
Have you had German measles (Rubella)*
Are you vaccinated with MMR vaccine (measles-mumps-rubella)*
Have you ever been infected with MRSA (methicillin resistant staphylococci)*
Have you within the last 6 months recieved treatment at a cliniq or a hospital abroad*
Have you within the last 6 months had contact to live pigs*

Gynecological

For how long have you tried to become pregnant?*
Have you ever been pregnant*
- What year
- with current partner
Have you ever had an abortion
Have you had a spontaneous abortion?
- when
- comments
Have you had a provoked abortion
- when
- comments
Have you previously had an extrauterine pregnancy?*
- When
Have you given birth before*
- Year
- vaginal birth/cesarean section
- in which gestational week
Does you and your companion/husband have kids together*
Does your kids live together with you
Are your periods regular*
First day of your latest menstruationPick date (dd-mm-yyyy)
Average number of days for your menstruation cycle
When was your latest smear from cervix (NHS)*
- year
Have you had abnormal cells*
- year
Have you had cone section
- year
Have you had Chlamydia
- year
When was your last examination for Chlamydia (month/year)
Have you had pelvic inflammatory disease*
- year
Do you have severe menstrual pain*
Do you suffer from endometriosis*
Have you been exemined for open fallopian tubes*
- when
Do you know the cause of your infertility
Have you previous been in fertility treatment*
Height in cm*
Weight in kilograms*
I allow Freya Fertility to seek relevant test results from Sundhed.dk (if living in Denmark)

Blood tests etc.

AMH*
- AMH value (xx,x)
FSH*
- FSH value (xx,x)
LH*
- LH value (xx,x)
TSH*
- TSH value (xx,x)
TPO antibodies*
TPO value
Prolactin*
- Prolactin value
HbA1C (Long-term blood sugar)*
- HbA1C value
HIV 1+2, no more than twenty-four months old*
Hepatitis B, no more than twenty-four months old*
Hepatitis C, no more than twenty-four months old*
Syphilis, no more than twenty-four months old*

Fertility treatment

What kind of treatment are you interested in*

All employees at Freya Fertility will be able to access your journal in addition, and there are administrative staff, who can access the journal to handle finances, statistics, reports etc.

Have you read and accepted the above mentioned for your treatment?

The partner

Information about the man

Female partner

Given name*
Family name*
Address*
Place
Zip code*
City*
Country*
Identification number/date of birth*
Email
Your occupation*
Mobile*
Weight in kilograms*
Height in cm*
Tobacco*
- How many cigarettes a day
Alcohol*
- Number of drinks per week
Do you take any medication*
Write name, strength, dose and reason - also OTC drugs/herbal medicine
Allergies*
- to which medicine and what is the reaction
Have you been taking medication against depression, anxiety or other mental disorder*
- for what kind of disorder, what kind of treatment
Do you suffer from chronic diseases*
- which ones
Have you had lack of descent for one or both testicles *
Have you had infections of the testicles/epididymes e.g. Chlamydia *
Have the testicles been exposed to severe trauma or any other kind of damage*
Have you had any surgery of the testicles or penis*
- When and for what reason
Have you had surgery for hernia*
Have you achieved pregnancy with anyone else than your current partner*
Have you had a semen analysis done*
- Where and when
- How was the result
I allow Freya Fertility to seek relevant test results from Sundhed.dk (if you live in Denmark)

Please remember to fill out consent about maternity when using assisted reproduktion (børnelovens §27 and 27b) Has to be filled out before the treatment starts (if you live in Denmark)

Contact to Freya Fertility

Have you already made an appointment with Freya Fertility
DatePick date (dd-mm-yyyy)
Are you interested in a consultation at Freya Fertility
Are you interested in a phone consultation
When does it suit you?

Private policy

When starting fertility treatment at Freya Fertility, we will handle sensitive personal information. We therefor ask you to read the Privacy Policy Patients from the clinic

I/we consent to Freya Fertility recieveing, registering, processing and storing my/our personal information*
I/we agree that communication with Freya Fertility via phone/Teams or SMS is not encrypted*

Freya Fertility only use the information when relevant to the treatment. We keep the information, and do not pass on any information besides what the law demands and what your accept. The protection of your data happens according to the Privacy Policy

You have the right to withdraw your consent. If you revoke your consent, it does not affect the treatment prior to withdrawal on your consent, including disclosure based on prior consent

By filling out the contactformular, I accept that above mentioned personal data are kept and are being used to answer my inquiry. Further information can be found in our Privacy Policy