Questionnaire regarding your Health
The Woman
First name: *
Family name: *
Address: *
Zip Code: *
City: *
Country: *
Andorra
United Arab Emirates
Afghanistan
Anguilla
Albania
Armenia
Netherlands Antilles
Angola
Antarctic
Argentina
American Samoa
Austria
Australia
Aruba
Azerbaijan
Bosnia and Herzegovina
Barbados
Bangladesh
Belgium
Bukino Faso
Bulgaria
Bahrain
Burundi
Benin
Bermuda
Brunei
Bolivia
Brazil
Bahamas
Bhutan
Bouvet Island
Botswana
Belarus
Belize
Canada
Cocos (Keeling) Islands
The Democratic Republic Of The Congo
Central African Republic
Congo
Switzerland
Côte d'Ivoire
Cook Islands
Chile
Cameroon
China
Colombia
Costa Rica
Serbia and Montenegro
Cuba
Cape Verde
Christmas Island
Cyprus
Czech Republic
Germany
Djibouti
Denmark
Dominica
Dominican Republic
Algeria
Ecuador
Estonia
Egypt
Western Sahara
Eritrea
Spain
Ethiopia
Finland
Fiji
Falkland Islands
Federated States of Micronesia
Faroe Islands
France
Gabon
Great Britain
Grenada
Georgia
French Guiana
Ghana
Gibraltar
Greenland
Gambia
Guinea
Guadeloupe
Equatorial Guinea
Greece
South Georgia and the South Sandwich Islands
Guatemala
Guam
Guinea-Bissau
Guyana
Hong Kong
Heard Island and McDonald Islands
Honduras
Croatia
Haiti
Hungary
Indonesia
Ireland
Israel
India
British Indian Ocean Territory
Iraq
Iran
Iceland
Italy
Jamaica
Jordan
Japan
Kenya
Kyrgyzstan
Cambodia
Kiribati
Comoros
Saint Kitts and Nevis
South Korea
North Korea
Kuwait
Cayman Islands
Kazakhstan
Laos
Lebanon
Saint Lucia
Liechtenstein
Sri Lanka
Liberia
Lesotho
Lithuania
Luxembourg
Latvia
Libya
Morocco
Monaco
Moldovia
Madagascar
Marshall Islands
Macedonia
Mali
Myanmar
Mongolia
Macau
Mariana Islands
Martinique
Mauritania
Montserrat
Malta
Mauritius
Maldives
Malawi
Mexico
Malaysia
Mozambique
Namibia
New Caledonia
Niger
Norfolk Islands
Nigeria
Nicaragua
Netherlands
Norway
Nepal
Nauru
Niue
New Zealand
Oman
Panama
Peru
French Polynesia
Papua New Guinea
Philippines
Pakistan
Poland
Saint-Pierre and Miquelon
Pitcairn
Puerto Rico
Palestine
Portugal
Palau
Paraguay
Qatar
Réunion
Rumania
Russia
Rwanda
Saudi Arabia
Solomon Islands
Seychelles
Sudan
Sweden
Singapore
Saint Helena
Slovenia
Svalbard and Jan Mayen
Slovakia
Sierra Leone
San Marino
Senegal
Somalia
Suriname
Sao Tome and Principe
El Salvador
Syria
Swaziland
Turks and Caicos Islands
Chad
French Southern Territories
Togo
Thailand
Tajikistan
Tokelau
Timor-Leste
Turkmenistan
Tunisia
Tonga
Turkey
Trinidad and Tobago
Tuvalu
Taiwan
Tanzania
Ukraine
Uganda
United States Minor Outlying Islands
United States
Uruguay
Uzbekistan
Vatican City State
Saint Vincent and the Grenadines
Venezuela
British Virgin Islands
U.S. Virgin Islands
Vietnam
Vanuatu
Wallis and Futuna
Samoa
Yemen
Mayotte
South Africa
Zambia
Zimbabwe
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?: *
Yes
No
Marital status: *
Single
Married
Cohabiting
Other
Your partners gender: *
No partner
Male
Female
The Partner – Female or Male
First name: *
Family name: *
Address: *
Zip code: *
City: *
Country: *
Andorra
United Arab Emirates
Afghanistan
Anguilla
Albania
Armenia
Netherlands Antilles
Angola
Antarctic
Argentina
American Samoa
Austria
Australia
Aruba
Azerbaijan
Bosnia and Herzegovina
Barbados
Bangladesh
Belgium
Bukino Faso
Bulgaria
Bahrain
Burundi
Benin
Bermuda
Brunei
Bolivia
Brazil
Bahamas
Bhutan
Bouvet Island
Botswana
Belarus
Belize
Canada
Cocos (Keeling) Islands
The Democratic Republic Of The Congo
Central African Republic
Congo
Switzerland
Côte d'Ivoire
Cook Islands
Chile
Cameroon
China
Colombia
Costa Rica
Serbia and Montenegro
Cuba
Cape Verde
Christmas Island
Cyprus
Czech Republic
Germany
Djibouti
Denmark
Dominica
Dominican Republic
Algeria
Ecuador
Estonia
Egypt
Western Sahara
Eritrea
Spain
Ethiopia
Finland
Fiji
Falkland Islands
Federated States of Micronesia
Faroe Islands
France
Gabon
Great Britain
Grenada
Georgia
French Guiana
Ghana
Gibraltar
Greenland
Gambia
Guinea
Guadeloupe
Equatorial Guinea
Greece
South Georgia and the South Sandwich Islands
Guatemala
Guam
Guinea-Bissau
Guyana
Hong Kong
Heard Island and McDonald Islands
Honduras
Croatia
Haiti
Hungary
Indonesia
Ireland
Israel
India
British Indian Ocean Territory
Iraq
Iran
Iceland
Italy
Jamaica
Jordan
Japan
Kenya
Kyrgyzstan
Cambodia
Kiribati
Comoros
Saint Kitts and Nevis
South Korea
North Korea
Kuwait
Cayman Islands
Kazakhstan
Laos
Lebanon
Saint Lucia
Liechtenstein
Sri Lanka
Liberia
Lesotho
Lithuania
Luxembourg
Latvia
Libya
Morocco
Monaco
Moldovia
Madagascar
Marshall Islands
Macedonia
Mali
Myanmar
Mongolia
Macau
Mariana Islands
Martinique
Mauritania
Montserrat
Malta
Mauritius
Maldives
Malawi
Mexico
Malaysia
Mozambique
Namibia
New Caledonia
Niger
Norfolk Islands
Nigeria
Nicaragua
Netherlands
Norway
Nepal
Nauru
Niue
New Zealand
Oman
Panama
Peru
French Polynesia
Papua New Guinea
Philippines
Pakistan
Poland
Saint-Pierre and Miquelon
Pitcairn
Puerto Rico
Palestine
Portugal
Palau
Paraguay
Qatar
Réunion
Rumania
Russia
Rwanda
Saudi Arabia
Solomon Islands
Seychelles
Sudan
Sweden
Singapore
Saint Helena
Slovenia
Svalbard and Jan Mayen
Slovakia
Sierra Leone
San Marino
Senegal
Somalia
Suriname
Sao Tome and Principe
El Salvador
Syria
Swaziland
Turks and Caicos Islands
Chad
French Southern Territories
Togo
Thailand
Tajikistan
Tokelau
Timor-Leste
Turkmenistan
Tunisia
Tonga
Turkey
Trinidad and Tobago
Tuvalu
Taiwan
Tanzania
Ukraine
Uganda
United States Minor Outlying Islands
United States
Uruguay
Uzbekistan
Vatican City State
Saint Vincent and the Grenadines
Venezuela
British Virgin Islands
U.S. Virgin Islands
Vietnam
Vanuatu
Wallis and Futuna
Samoa
Yemen
Mayotte
South Africa
Zambia
Zimbabwe
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: *
Yes
No
The woman
General information
How long have you tried to become pregnant? No of months:
Allergies?: *
Yes
No
- What?:
.
Medication: *
Yes
No
- Name and Dose::
.
Folic acid: *
Yes
No
Herbal Medicine: *
Yes
No
- Name and Dose::
.
Tobacco?: *
Yes
No
- No. of cigarettes per day:
Alkohol?: *
Yes
No
- No. of glasses per week:
33cl, regular (5%vol) beer is approximately one danish standard drink
Are you fit and healthy?: *
Yes
No
- What ails you?:
.
Have you had any surgery?:
Yes
No
- When and for what?:
.
Hereditary diseases?:
Yes
No
- What:
.
Have you ever had a thrombosis?:
Yes
No
- When and where?:
.
Occupation:
.
Gynaecological Information
Do you have regular periods?: *
Yes
No
My last period started: *
(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?:
Yes
No
- Year:
Have you had a conic sectioning of the cervix?:
Yes
No
- Year:
Have you had a Chlamydia infection?:
Yes
No
- Year?:
When was you last tested for Chlamydia? (Enter month/year):
Have you had a pelvic inflammation?:
Yes
No
- Year?:
Do you have strong menstrual cramps?:
Yes
No
Do you have Endometriosis?:
Yes
No
- Since when?:
Have you had investigated the passage of your Tubes?:
Yes
No
- When? (Enter month/year):
- What Method?:
HSG
Laparoscopy
HSU
- 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?:
Yes
No
Do you have children with your actual partner?:
Yes
No
Have you been in fertility treatment before?:
Yes
No
- When and what treatment?:
Have you had German Measles?:
Yes
No
Are you vaccinated against German Measles?:
Yes
No
Do you have results of the statutory tests for HIV and Hepatitis?:
Yes
No
- Date of Analyses?:
(dd-mm-yyyy)
HIV:
Positive
Negative
Anti-HBc:
Positive
Negative
HBsAg:
Positive
Negative
Anti-HCV:
Positive
Negative
Is the laboratory accredited according to DIN EN 15189 or 17025:
Yes - Please provide us with a copy of the certificate
No
Your height(cm): *
Your weight(kilogram): *
The partner
General information
Allergies?: *
Yes
No
- What:
.
Medication?: *
Yes
No
- Name and Dose:
.
Folic acid?: *
Yes
No
Herbal Medicine?: *
Yes
No
- Name and Dose:
.
Tobacco?: *
Yes
No
- No. of cigarettes per day:
Alkohol?: *
Yes
No
- No. of glasses per week:
Are you fit and healthy?: *
Yes
No
- What ails you:
.
Have you had any surgery?:
Yes
No
- When and what?:
.
Hereditary diseases?:
Yes
No
- What?:
.
Have you ever had a thrombosis:
Yes
No
- When and where:
.
Occupation:
.
Andrology
Do you have children with another woman?:
Yes
No
- Number?:
Have you have made a semen analysis?:
Yes
No
- Result?:
Have you had any Chlamydia infections?:
Yes
No
- Year?:
Have you had other infections of the urinary tract or testicles?:
Yes
No
- What infection?:
Have you been operated for undescended testicles?:
Yes
No
- Year?:
Have you had any operations in your testicles?:
Yes
No
- When and why?:
Have you had any damage to your testicles?:
Yes
No
- When and what?:
Do you have any genital malformations?:
Yes
No
- What kind?:
Have you been operated for hernia?:
Yes
No
- Year?:
Do you have results of the statutory tests for HIV and Hepatitis?:
Yes
No
- Date of Analyses?:
(dd-mm-yyyy)
HIV:
Positive
Negative
Anti-HBc:
Positive
Negative
HBsAg:
Positive
Negative
Anti-HCV:
Positive
Negative
Is the laboratory accredited according to DIN EN 15189 or 17025:
Yes - Please provide us with a copy of the certificate
No
Your weight (kilogram): *
Your height (cm): *
Send