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 menstruation: Pick 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 or urinary tract, 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 :
Pick date (dd-mm-yyyy)
Are you interested in a free consultation at Freya Fertility:
Are you interested in a free phone consultation:
What time would you prefer?:

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 accept that Freya Fertility recieve, register and store the sensitive personal information: *
I/we accept that communication with Freya Fertility via phone/skype 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