Electronic record

To be able to help you the best way we kindly ask you to fill-in as much as possible of the below questions. It there are any questions you cannot answer we can talk about it when we have the initial conversation.

Contact data

First name*
Last name*
Date of birth/Civil reg. no.*
Address*
Postal code*
Town/City*
Country*
Phone number
Mobile*
E-Mail*
Repeat email *
Do you have a partner/spouse*
Partner’s firstname*
Partner’s last name*
Partner’s Date of birth*
Partner’s address*
Partner’s e-email*
Repeat email *
Partner´s gender*

General information about you

What treatment are you looking for*
Which type of work do you have? - important for us to know in relation to pregnancy
Are you suffering from, physical or mental illness*
Are you taking any medication? (Inclusive psychotropic medication or painkillers)*
- which
Are your periods regular*
How many days are your cycle? (e.g. 28 days)
Have you been pregnant
Your height in cm*
Your weight in kilograms*
Have you been assessed by a healthcare professional and diagnosed with a known fertility problem?*
*
*

Some viral infections are more common in certain parts of the world and may affect fertility treatment.

Have you been in areas where Zika virus may occur (e.g. South and Central America, the Caribbean, Southeast Asia or Africa) in the past 3 months?*
Are you born or have you visited areas HTLV may occur (e.g. Japan, South America, the Caribbean or Africa) ?*
Have you received a blood transfusion or had unprotected sexual contact in these areas?*
Have you previously undergone fertility treatment?*
*
How many times?*

Blood tests and other examinations

If you have taken any of these tests, we kindly ask you to e-mail us a copy of the results - if possible before the initial conversation: AMH, TSH, anti-TPO, FSH, LH, Estradiol, AFC (follicle scan), HSU/HCG (examination of your fallopian tubes)

Sperm for the treatment

Are you going to use sperm from a donor, from your partner or from a known donor e.g. a friend
Are there any other relevant information you want to share with us? - please write here

Declaration

I/we confirm that I/we have received written information (from website or forwarded by Vitanova) on fertility treatment, and that the information I/we have provided is true and correct.

Do you agree with the above declaration?*