Personal Medical Statement

First name: *
Last name: *
Birth date (ddmmyy): *
Address: *
Postal code: *
City: *
Country: *
Home phone number:
Mobile phone number: *
Email: *
Repeat email *
Skype ID (if applicable):
Current employment/full-time study:
Have you or your partner previously been treated at StorkKlinik: *
Partner´s sex: *

Partner

Personal information about partner

First name: *
Last name: *
Birth date: *
Address: *
Country: *
Home phone number:
Mobile phone number: *
Email: *
Repeat email *

For you going into treatment

General Medical History

Current/previous illnesses and year:
Mental disorders (including depression, etc.):
Admissions to hospital or surgeries and year (If possible, please send us description of surgery):
Are you taking medication on a daily basis? (Remember that birth control pills and pain relievers are also medication): *
- What medication and for what?:
Current or past use – which medication and what year? – Birth control pills, pain relievers and allergy medicine are also medication!:

Have you discussed whether the medication is compatible with future pregnancy?

We recommend that medication intake is discussed with your doctor.

Have you previously had MRSA detected, and have you not been declared free of MRSA? (A person is free of MRSA when there have been at least 3 sets of negative MRSA swabs after ended treatment, and the last swab is taken at least 6 months after ended treatment): *
Have you within the last 6 months been in contact with a person positive for MRSA?: *
Have you within the last 6 months been treated at a hospital or clinic abroad (outside the Nordic countries)?: *
Has the duration of the stay been over 24 hours?:
Has any invasive procedure been performed (e.g. stablishing an IV line, drain/catheter, dialysis, stitching of wounds, aspiration of eggs, transfer of eggs – no matter the duration of the stay)? (In this connection injections and blood sampling are not considered invasive procedures):

Lifestyle

How many fruits and vegetable (minus potatoes) do you eat daily?: *
How often do you eat fish:
Do you take vitamin- or mineral supplements?:

The Danish Health Authorities recommend 400 µg of folic acid a day

Do you have any allergies?: *
- What allergies:
Are you allergic to eggs?: *
- What symptoms:
Do you exercise regularly?:
- What kind of exercise:
Coffee - number of cups per day:
Beer, wine, liquor – how many units per week?:
Cigarettes/snuff - how many daily?:
Weight in kilograms: *
Height in centimetres: *
How comfortable are you regarding your weight on a scale from 0 to 10, 0 being ‘Not comfortable at all’ and 10 being ‘Very comfortable’:

Previous pregnancies

Number of previous pregnancies and years these took place:
How many pregnancies were planned (please state which year):
Number of abortions:
- Please state week of pregnancy and year:
Number of miscarriages?:
- Please state week of pregnancy and year:
Were there complication with the abortions:
- What complications/infections:
Previous births (state year):
Were there any complications giving birth, e.g. caesarean?:
- What complications:

Previous attempts to become pregnant

Have you been in fertility treatment before? (If possible please send copy of medical journal):
Type of treatment:
- Number of treatments:
Type of treatment:
- Number of treatments:
Type of treatment:
- Number of treatments:
Type of treatment:
- Number of treatments:
Please state year(s) for previous fertility treatments and other planned pregnancy attempts (Please state how long you tried number of years/months and what year):

Fertility examination at the gynaecologist

Did your ultrasound show cysts, fibroids, polyps or other abnormalities:
- When: Pick date (dd-mm-yyyy)
- Description:

There are a number of requirements and/or recommendations for fertility examinations before you start. We ask you to please read the information package for IVF/ICSI and insemination respectively.

Is your gynaecologist estimate that you are fertile and that insemination will provide you with actual chance of pregnancy?:
- Comments:

At your own doctor or gynaecologist

Be aware that the requirements for testing for HIV, Hepatitis B and C, Chlamydia and smear depending on whether you are going to be inseminated or going into IVF/ICSI treatment. In the information packages and on the website for insemination and IVF/ICSI respectively it clearly states which tests need to be done and whether they can be done here at the clinic.

Fallopian tubes

Previous pelvic infections including chlamydia infections: *
- Please state year and how many. Please state whether one or more were Chlamydia infections:
X-ray examination of Fallopian tubes, HSG:
- When?: Pick date (dd-mm-yyyy)
Water scan of Fallopian tubes, HSU:
- When?: Pick date (dd-mm-yyyy)

Menstrual intervals/Menstrual cycle for the past 6 months

Count from first day of your period to the day before your next period’s first day – REMEMBER write only the intervals (number of days), not the dates!

1st cycle:
2nd cycle:
3rd cycle:
4th cycle:
5th cycle:
6th cycle:

Donor

Remember genes can skip a generation. Your baby will look like itself most of all! There is no guarantee that the baby will be a mix between your height and colours and those of the donor. Please think carefully about why it is important to you to have a donor with specific characteristics. Below you can specify if you want a donor with certain eye- or hair colour or height.

REMEMBER: All donors are Caucasian unless you special order so-called ethnic donor sperm.

At StorkKlinik we have two types of donors – ‘Anonymous donor’ and ‘Open donor’. You can also use sperm from a donor you know. This is called ‘Known donor’.

On the website the difference between the types of donor are explained, and you can also read about donors with ‘extended profile’.

If you want to book / reserve semen from one of the sperm banks, we can only accept to receive the sperm in the clinic after you had the initial conversation with us.

Are you considering using donor sperm?: *
Do you want to use sperm from a known donor:
Do you want to use sperm from an open donor or anonymous donor?:

Donor requests

Do you have any special wishes regarding donor´s characteristics?:
Eye colour:
Is eye colour?:
Hair colour:
Is hair colour?:
Height:
Is height?:

Partner

Infections/illnesses in the sex organs

Have you had mumps (Acute viral parotitis) after puberty?: *
Have you had infections in the epididymis? (Chlamydia, gonorrhea or other): *
- Description:
Have you had issues with undescended testes?: *
Have you had surgery for ingunial hernia?: *
Have you been treated for cancer?: *
- When?: Pick date (dd-mm-yyyy)
- Location:
Have you had radiation therapy of your testicles?: *
Have you received chemotherapy?: *

Account of childlessness and marital relations

Have you had a sperm analysis done? (If yes, please bring a copy of the analysis): *
- When?: Pick date (dd-mm-yyyy)
- Enter the result and location:
Have you become pregnant with previous partner?: *
Are there any factors in your marital relations that makes becoming pregnant difficult?: *
- What factors:

General questions

Are you allergic/sensitive to any medication?: *
- What medication and how do you react?:
Are you taking medication on a daily basis?: *
- What medication and for what?:
Cigarettes/snuff - how many daily?:
Beer, wine, liquor – how many units per week?:
Weight in kilograms:
Height in centimetres:
Have you been treated in hospital or by specialist/GP for any other conditions?:
- Which condition and what year:
- Where:
- What:

I hereby solemnly confirm the accuracy of the above information. I confirm to have carefully read StorkKlinik’s or Stork IVF Klinik’s informations.

I understand and accept that I cannot receive fertility treatment, if I have not supplied the obligatory tests, which differ for StorkKlinik and StorkIVF. (Cf. information material for HIV, Hep B, Hep C, Chlamydia and smear).

If I have been undergoing hormone stimulation (tablets or injections) in the current cycle, I am required to have an ultrasound scan performed a few days prior to insemination (see pages 9 -10 in the document mentioned above). I agree that I cannot be inseminated if a scan is not available.

If I use sperm from my male partner, I agree that the semen cannot be received and used unless there are negative test results for HIV, Hepatitis B in the form of anti-HBc and HBsAg and Hepatitis C. Samples must be analyzed by a laboratory which is approved by the Danish authorities or at Stork IVF Klinik. If I purchase sperm from sperm banks, I undertake to purchase from a sperm bank approved by the Danish authorities. StorkKlinik have sole responsibility for sperm that I buy through StorkKlinik or Stork IVF Klinik.

If the child is sick at birth or in the first year of its life and you are told that it may be hereditary, it is important that you report back to the clinic, in order to determine whether the donor may continue to be used. The same applies if you are told that it could be due to transmission from the donor. Although the donor is tested for being free of communicable diseases such as HIV and Hepatitis, the risk is never zero.

Under Danish law, the clinic is obliged to report individual treatments to the health authorities for statistical purposes. Furthermore, the data is used statistically for the clinic's continuous internal quality assurance.

StorkKlinik cannot be held responsible for the outcome or consequences of an event of pregnancy.

I am obligated to notify StorkKlinik of the outcome of each fertility treatment.

I wish to be inseminated under the described conditions.

Have you read and accept form of consent above?: *

This clinic is part of the VivaNeo group in Denmark, where all employees with revelance to your treatment will have access to your journal.

Furthermore, there is administrative staff who will have access to your journal in order to carry out tasks related to economics, statistics, reports, etc.

Have you read and accept form of consent above?: *
Has partner read and accepted form of consent above?:

Private policy

Stork Klinik Viva Neo would like to help you with fertility treatment, and in this regard, it is important for the clinic to take care and protect your privacy and personal sensitive data, which we receive from your treatment. Thus, we advise/recommend you to read the clinic's ”Privacy Policy”

I/We consent to, that Stork Klinik Viva Neo receives, records, processes and stores my/our personally sensitive data.: *
I/We consent to, that communication with the clinic by phone or/and Skype are not encrypted.: *

The clinic only uses the information when relevant to your fertility treatment. The clinic protects the information carefully, and do not pass them on beyond what legislation requires and you consent to. The clinics protection of your data is in accordance with the Danish Personal Data Act and the EU Data Protection Regulation.

You can revoke your consent at any time by contacting Stork Klinik Viva Neo at +45 32 57 33 16 /+ 45 70 60 60 90 / info@storkklinik.dk . Any withdrawal of consent will not affect treatment or obligations from before your withdrawal of consent.

We encourage you to sign up for our newsletter and receive relevant and important information in regards to your fertility treatment:

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By submitting the contact request form I agree that the above-mentioned personal data will be stored for processing my contact request. Further information can be found in our privacy policy.