Questionnaire for the woman

Contact information

First name*
Surname*
CPR number or date of birth (dd-mm-yy)*
Address*
Postal code*
City*
Country*
Phone number*
E-mail*

General questions

Marital status and occupation

What is your marital status?*
Are you related to your male partner?*
What is your job occupation?*

Preliminary question

How long have you been trying to get pregnant? (write the number of months you have tried)*

Medical history

Are you allergic to any type of medicine*
Please specify the type of medicine and the type of allergic reaction*
Do you take any medicine on a daily basis?*
Which medicine and what dosage? (nutritional supplements excluded)*
Do you have any medical or mental illnesses?*
Please describe the illnesses by diagnoses or short descriptions*
Have you ever had surgery? (orthopedic surgery excluded)*
Please specify year of surgery, type of surgery and reason, e.g. "2020, laparoscopy, appendicitis"*
Are there other matters which are important for us to know about your medical and mental health?*
Please decribe here.*

Lifestyle

How tall are you? (please specify height in cm)*
What do you weigh? (please specify weight in kg)*
How many units of alcohol do you consume in a week? (average consumption)*
Do you smoke?*
How many cigarettes do you smoke daily? (average consumption)*
Do you use other tobacco preparations? (snus/snuff, vape, e-cigarette, other)*
Please describe the sort of tobacco and the amount used daily*
Do you exercise?*
Please specify your choice of exercise and time spent weekly*
Do you take a dietary supplement with 400 micrograms of folic acid daily?*
Do you take other nutritional supplements?*
Please specify the supplements here
Are there other things that are important for us to know about your lifestyle?*
Please specify here.

Gynecology

Menstrual cycle

What is the average length of your menstrual cycle in days? e.g. "26-28 days", ">40 days", "I do not get my period"*
What is the average length of your menstrual bleeding in days? (only fresh red bleeding included, spotting excluded)*
When was the first day of your last period? (dd-mm-yy)*

Previous contraception

Have you ever had an IUD?*
Please describe the time period where you used the IUD*
Have you ever used birth control pills or minipills?*
Please describe the time period where you used oral contraceptives*

Previous pregnancies

Have you been pregnant before?*
Do you have children?*
Did you conceive your child/your children using donor sperm?*
Please specify the Sperm bank and the donor used
Please describe all your previous pregnancies (childbirths, induced abortions, miscarriages, ectopic pregnancies, biochemical pregnancies). Please describe in chronological order. (year, obtained +/- help, result and if any treatment) e.g. "2017, "homemade", miscarriage, termination with medical treatment", "2022, fertility treatment with insemination (IUI), pregnant and subsequent birth"*

Previous or current gynecological diseases

Do you have severe menstrual pain? (pain that requires regular painkillers)*
Have you previously had pelvic inflammatory disease (PID) such as chlamydia infection? (cystitis excluded)*
Have you had a fallopian tubes examination (HyCoSy)?*
Please describe what year and the result of the examination, e.g. "2021, normal passage", "2023, left side without passage, right side open"*
Have you had a cone biopsy of you cervix due to dysplasia of the cervical cells?*
Please describe the year(s) of the procedure(s)*
Have you had any surgery on your ovaries, fallopian tubes or uterus? (C-section included)*
Please describe year and type of surgery, reason and result*
Have you had a curettage of your uterus (also called D&C) after a miscarriage or due to retained tissue after childbirth?*

We have asked you to test for chlamydia infection prior to your appointment in the clinic either at your GP or from home using a self test kit

Please specify the date of negative chlamydia test here (dd-mm-yy)
Are there other matters which are important for us to know about your gynecological health?*
Please describe here

Previous fertility treatment

Have you previously undergone fertility treatment?*
Please note the number of insemination treatments, including the year of treatment, where you were treated and the result, e.g. "3 cycles, in 2023 by my gynecologist, one biochemic pregnancy, the rest negative"
Please describe the completed IVF/ICSI cycles in chronological order (year, where, type of treatment and outcome), e.g. "2017, Herlev Hospital, IVF, short protocol with Menopur 225IU, pregnant and childbirth"*
Please describe the completed eggdonation cycles in chronological order (year, where, type of treatment and outcome), e.g. "2022, Stork Klinik, one donation, 3 transfers, 2 negative tests and one pregnancy with subsequent birth
Are there other matters which are important for us to know regarding your previous fertility treatments?*
Please describe here

Final question

How did you hear about and choose Trianglen as your fertility clinic?*
Please describe here