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 results on e-mail?*
Civil status*
Partners gender*

Partner

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

Female

General information

How long have you tried to become pregnant (months)?*
Allergies?*
-Which?
Are you taking any medication?*
-Name and dose
Folic acid?*
Herbal medicine?*
-Name and dose
Dietary supplements?*
-Name and dose
Do you smoke?*
-Type and amount pr. day
Alcohol?*
-Amount pr. week

33cl, regular (5%vol) beer is approximately one danish standard drink

Coffee?*
Cups pr. day
How often do you exercise pr. week?*
Are you fit and healthy?*
-What ails you?
Have you had any suregery?*
-When and for what?
Hereditary diseases?*
-What diseases?
Have you ever had a thrombosis?*
-When and where?
Your occupation

Gynecological

Is your menstrual cycle regular?*
Lenght of bleeding (days)*
Cycle length (1st day of period until the next 1st day)*
When did your last menstruation start?*
When did you last time have a PAP-smear from your cervix (enter year)*
Have you had a pathological smear?*
-Enter year
Have you had a conic sectioning of the cervix?*
-Enter year
Have you ever had a chlamydia infection?*
-Enter year
When was 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 had investigated the passage of your tubes?*
-When?
-With X-ray, operation or ultrasound?
-Results of the investigation
Have you ever been pregnant?*
-No. of pregnancies*
-Year of pregnancies
-Number of births*
Year of births
Number of miscarriages/abortions*
-Number of ectopic pregnancies*
Have you been pregnant with your actual partner?*
Do you have children with your actual partner?*
Have you ever had fertility treatment before?*
-When and what kind of treatment?*
Have you had German Measles?*
Have you been vaccinated against German Measles?*
Have you been vaccinated against HPV virus?*
Have you been infected with MRSA (methicillin resistant staphylococci)*
Have you been in contact with people infected with MRSA within the last 6 months?*
Have you received treatment in a hospital or clinic outside Denmark within the last 6 months?*
Have you been in contact with living pigs or mink within the last 6 months?*
Your weight in kg*
Your height in cm*
I give my permission that the clinic may access relevant medical information and test results from Sundhed.dk*
I accept the clinics GDPR policy (see homepage)*
We cannot offer treatment withour your accept

Partneren

Generelle oplysninger

Allergies?*
-What allergies?
Medication?*
-Name and dose
Folic acid?*
Herbal medicine?*
-Name and dose
Dietary supplements*
-Name and dose
Do you smoke?*
-Type and no. per day
Do you drink alcohol*
-No. of drinks per week
Do you drink coffee?*
- No. of cups per day
How often do you exercise per week?*

Are you fit and healthy?*
-What ails you?
Have you had any surgery?*
- When and for what?
Any hereditary diseases?*
- What?
Have you ever had a thrombosis?*
- When and where?
Are you and your partner cousins?*
Are some of your parents cousins?*
Your occupation

Andrologisk

Do you have children from previous relationships?*
- How many?
Have you have made a semen analysis?*
- What was the result?
Have you had any chlamydia infections?*
- What year
Have you had other infections of the urinary tract or testicles?*
- What infections?
Have you been operated for undescended testicles?*
- Enter year
Have you had any operations in your testicles?*
- For what and when?
Have you had any damage to your testicles?*
- What and when?
Do you have any genital malformations?*
- What malformations?
Have you been operated for hernia?*
- Enter year
Have you been infected with MRSA (methicillin resistant staphylococci)*
Have you been in contact with people infected with MRSA within the last 6 months?*
Have you received treatment in a hospital or clinic outside Denmark within the last 6 months?*
Have you been in contact with living pigs or mink within the last 6 months?*
Your weight in kg*
Your height in cm*
I give my permission that the clinic may access relevant medical information and test results from Sundhed.dk*
I accept the clinics GDPR policy (see homepage)*
We cannot offer treatment without your acceptance