Patient Questionnaire

I hereby give consent to the processing of my personal data and I hereby declare that I have provided complete and truthful information in this questionnaire. I am aware of the fact that the clinic cannot be held responsible for the damages caused by incomplete or inaccurate information provided by others.

Please choose your treatment *

Personal data

Female

Male

Full name *

Date of birth *

Occupation

Contact details

Telephone *

Best times to call

Email *

Skype

Address *

Country

I prefer communication via

Phenotype information

Female

Male

Height *

Weight *

Hair color *

Hair type *

Eye color *

Blood type Rh Factor *

Anamnesis – Female

Family

1. Do you have any serious illnesses or conditions which run in your family? *

YesNo

General Health

2. Have you ever had thrombosis or thrombophlebitis? *

YesNo

3. Have you had serious or reoccurring illnesses or repeated exams due to a specific condition in the past? *

YesNo

4. Have you ever had general anaesthesia? *

YesNo

5. Are you on any long-term medications? *

YesNo

6. Do you have any allergies? *

YesNo

7. Are you a smoker? *

YesNo

Gynaecological History

8. Previous Pregnancies? *

YesNo

Current partner or with previous

Pregnancy complications

End of pregnancy

Pregnancy

Notes (for example Caesarean section)

9. Age when periods first started (years) *

10. Frequency of your cycle (Example: regular, 28 days) *

11. How many days does your period last? *

12. Date of the last menstrual period *

13. Are your periods painful? *

YesNo

14. Have your periods ever stopped (excluding pregnancy)? *

YesNo

15. Does your gynaecologist regularly examine for breast cancer, cysts, myomas? *

YesNo

16. Do you attend periodical preventive gynaecological examinations? *

YesNo

17. Date of last PAP smear *

18. Has your gynaecologist informed you that your last PAP smear was normal? *

YesNo

19. Have you ever had an abnormal result? *

YesNo

20. Are you able to undergo hormonal treatment for IVF embryo transfer (ET) on hormonally prepared endometrium (HRT) and become pregnant according to your gynaecologist’s statement? *

YesNo

21. Contraception
Pills

YesNo

Pill brand

Start date

End date

Intrauterine device

YesNo

Device type

Start date

End date

Other

YesNo

22. Have you had a history of
Sexually transmitted disease *

YesNo

Pelvic inflammatory disease *

YesNo

Surgery on fallopian tubes *

YesNo

Removal of your appendix *

YesNo

Surgery on your cervix *

YesNo

Any other abdominal operations? *

YesNo

Infertility History

23. How long have you been trying to conceive? *

24. Have you had an ovulation induction with or without intrauterine insemination (IUI) *

YesNo

Cycle
Date

Clomid

Gonado-tropins

Sperm from

Pregnancy

25. Previous infertility examinations

Laparoscopy *

YesNo

Immunology *

YesNo

Coagulation (eg. Leiden mutation (Factor V)) *

YesNo

FII – prothrombin gene mutation *

YesNo

Hysteroscopy *

YesNo

Hysterosalpingogram (HSG) *

YesNo

Cystic fibrosis (CFTR) *

YesNo

Genetic examination (karyotype) *

YesNo

26. Other previous infertility investigations *

YesNo

27. Have you ever had In-Vitro Fertilization (IVF) (- Frozen embryo transfer (FET)) or treatment using donated oocytes (oocyte donation or OD) *

YesNo

Cycle
Date

Eggs obtained

Eggs fertilized

ICSI
YesNo
Sperm from

No. of embryos transferred

Pregnancy

28. Results of blood tests

Hormone Levels

TSH

Prolactin

Month / Year

FSH

Estradiol

Month / Year

AMH (Please, specify units – ng/ml or pmol/l)

Month / Year

Anamnesis – Male

Family

29. Do you have any serious illnesses or conditions which run in your family? *

YesNo

General Health

30. Have you had serious or reoccurring illnesses or repeated exams due to a specific condition in the past? *

YesNo

31. Are you on any long-term medications? *

YesNo

32. Do you have any allergies? *

YesNo

33. Are you a smoker? *

YesNo

34. Have you ever had:

Undescended testicle *

YesNo

Surgery to bring down testicle *

YesNo

Surgery for hernia *

YesNo

Surgery for prostate enlargement *

YesNo

Accident involving your genitalia *

YesNo

Diagnosed sexually transmitted disease *

YesNo

Inflammation of testicle or epididymis *

YesNo

Mumps (as an adult) *

YesNo

Scrotal surgery (surgery to your testicle) *

YesNo

Vasectomy *

YesNo

Previous radiotherapy *

YesNo

Previous chemotherapy *

YesNo

If yes, give details.

35. Do you have any pregnancies/children from previous relationships? *

YesNo

36. Are you able to produce a semen sample with masturbation? *

YesNo

37. Previous infertility investigations and treatment?

Personal data

Female

Male

Contact details

Phenotype information

Female

Male

Anamnesis – Female

Family

General Health

Gynaecological History

Infertility History

Anamnesis – Male

Family

General Health

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