Questionnaire regarding your Health

The Woman

First name: *
Family name: *
Address: *
Zip Code: *
City: *
Country: *
Personnumer or Date of birth (6 digits, for example 280571): *
Phone no. daytime:
Cell phone no.: *
E-mail:
May we send you results per e-mail?: *
Marital status: *
Your partners gender: *

The Partner – Female or Male

First name: *
Family name: *
Address: *
Zip code: *
City: *
Country: *
Personnumer or Date of birth (6 digits, for example 280571): *
Phone no. daytime:
Cell phone no.: *
E-mail:
May we send you results per e-mail: *

The woman

General information

How long have you tried to become pregnant? No of months:
Allergies?: *
- What?:
Medication: *
- Name and Dose::
Folic acid: *
Herbal Medicine: *
- Name and Dose::
Tobacco?: *
- No. of cigarettes per day:
Alkohol?: *
- No. of glasses per week:

33cl, regular (5%vol) beer is approximately 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?:
Occupation:

Gynaecological Information

Do you have regular periods?: *
My last period started: *Pick date (dd-mm-yyyy)
Average lengths of your menstrual cycle in days (including menstruation):
When did you last time have a PAP smear from your cervix? (Enter year):
Have you had a pathological smear?:
- Year:
Have you had a conic sectioning of the cervix?:
- Year:
Have you had a Chlamydia infection?:
- Year?:
When was you last tested for Chlamydia? (Enter month/year):
Have you had a pelvic inflammation?:
- Year?:
Do you have strong menstrual cramps?:
Do you have Endometriosis?:
- Since when?:
Have you had investigated the passage of your Tubes?:
- When? (Enter month/year):
- What Method?:
- Result:
No. of Pregnancies:
Year(s):
No. of Births:
Year(s):
No. of Abortions:
No. of Ectopic Pregnancies:
Have you obtained pregnancies with your actual partner?:
Do you have children with your actual partner?:
Have you been in fertility treatment before?:
- When and what treatment?:
Have you had German Measles?:
Are you vaccinated against German Measles?:
Do you have results of the statutory tests for HIV and Hepatitis?:
- Date of Analyses?: Pick date (dd-mm-yyyy)
HIV:
Anti-HBc:
HBsAg:
Anti-HCV:
Is the laboratory accredited according to DIN EN 15189 or 17025:
Your height(cm): *
Your weight(kilogram): *

The partner

General information

Allergies?: *
- What:
Medication?: *
- Name and Dose:
Folic acid?: *
Herbal Medicine?: *
- Name and Dose:
Tobacco?: *
- No. of cigarettes per day:
Alkohol?: *
- No. of glasses per week:
Are you fit and healthy?: *
- What ails you:
Have you had any surgery?:
- When and what?:
Hereditary diseases?:
- What?:
Have you ever had a thrombosis:
- When and where:
Occupation:

Andrology

Do you have children with another woman?:
- Number?:
Have you have made a semen analysis?:
- Result?:
Have you had any Chlamydia infections?:
- Year?:
Have you had other infections of the urinary tract or testicles?:
- What infection?:
Have you been operated for undescended testicles?:
- Year?:
Have you had any operations in your testicles?:
- When and why?:
Have you had any damage to your testicles?:
- When and what?:
Do you have any genital malformations?:
- What kind?:
Have you been operated for hernia?:
- Year?:
Do you have results of the statutory tests for HIV and Hepatitis?:
- Date of Analyses?: Pick date (dd-mm-yyyy)
HIV:
Anti-HBc:
HBsAg:
Anti-HCV:
Is the laboratory accredited according to DIN EN 15189 or 17025:
Your weight (kilogram): *
Your height (cm): *