Investigation form

Female

First Name*
Last name*
Address*
Place (if applicable)
ZIP code*
City*
Country*
CPR number*
Mobile number*
E-Mail*
May we send you information by e-mail?*

General information

Describe your problem shortly*
Allergies*
What allergies?
Medication?*
-Name and dose:
Herbal medicine*
-Name and dose
Dietary supplements*
-Name and dose:
Are you smoking?*
-Type and no. per day:
Are you drinking alcohol?*
No. of drinks per week? 33 cl, regular (5%) beer is approx. one danish standard drink
Are you fit and healthy?*
-What ails you?
Have you had any surgery?*
-When and for what?
Hereditary diseases?*
-What?
Have you ever had a thrombosis?*
-When and where?

Gynecological

Age at first menstruation*
Do you have regular periods?*
Lenghts of your menstrual bleeding (days)*
Lengths of your cycle (including menstruation):*
My last period started:*
When was your last PAP-smear from your cervix (enter year)*
Have you ever had a pathological smear?*
-Enter year
Have you ever had a conic sectioning of your cervix?*
-Year:
Have you had a chlamydia infection?*
-Year:
When were you last tested for chlamydia (enter month/year)*
Have you ever had a pelvic inflammation?*
-Enter year:
Do you have strong menstrual cramps?*
Do you have endometriosis?*
-Since when?
Have you ever been pregnant?*
-Number of pregnancies
-Enter years
-No. of births
-Enter years
-No. of abortions/miscarriages
-No. of ectopic pregnancies
Have you had German Measles?*
Are you vaccinated against German Measles?*
Are you vaccinated against HPV-virus?*
Have you been infected with MRSA (Methicillin resistant staphylococci)?*
Have you been in contact with MRSA infected people within the last 6 months?*
Have you received treatment in a hospital or clinic outside Denmark within the last six months?*
Have you been in contact with pigs or mink within the last 6 months?*
Your weight in kg*
Your height in cm*
I give my permission that the clinic can access relevant information and test results at Sundhed.dk*
I accept the clinics GDPR policy (see homepage for more information)*