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.

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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