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?*
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*
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:
.
Dietary supplements*
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)
Lengths of your menstrual bleeding (days)
Lengths of your cycle (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 ISO 15189 or 17025
Yes - Please provide us with a copy of the certificate
No
Have you been infected with MRSA (methicillin resistant staphylococci)*
Yes
No
Have you been in contact with people infected with MRSA within the last 6 months*
Yes
No
Have you received treatment in a clinic or hospital within the last 6 months*
Yes
No
Have you been in contact with pigs or mink*
Yes
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
.
Dietary supplements*
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?
Hereditary diseases*
Yes
No
- What kind?
.
Have you ever had a thrombosis*
Yes
No
- Where
.
Are you and your partner cousins*
Yes
No
Are some of your parents cousins*
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 ISO 15189 or 17025
Yes - Please provide us with a copy of the certificate
No
Have you been infected with MRSA (methicillin resistant staphylococci)*
Yes
No
Have you been in contact with people infected with MRSA within the last 6 months*
Yes
No
Have you received treatment in a clinic or hospital within the last 6 months*
Yes
No
Have you been in contact with pigs or mink*
Yes
No
Your weight (kilogram)*
Your height (cm)*
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