Questionnaire

Basic information

Female

First name

Surname

Age

Nationality

ID card / passport number

Date of birth

Address

Mobile number

E-mail

Male

First name

Surname

Age

Nationality

ID card / passport number

Date of birth

Address

Mobile number

E-mail

Anamnesis

Menstruation

What is the length of your menstruation cycle?

How many days does your period usually last?

Are your periods painful?

Yes

No

Are your periods regular?

Yes

No

Space for notes

Have your periods ever stopped? (excluding pregnancy)

Yes

No

If YES state which year, and for how long each time

Previous pregnancies

Previous partner

Please fill month/year to the yellow brackets.

Parturition

Miscarriage

Interrupted pregnancy

Ectopic pregnancy

Present partner

Please fill month/year to the yellow brackets.

Parturition

Miscarriage

Interrupted pregnancy

Ectopic pregnancy

Please state any complications during pregnancy

Contraception

Oral contraception pill

Yes

No

Please mention any problems with their use and dates and duration of use:

IUCD (Intrauterine contraceptive device)

Yes

No

Please mention any problems with their use and dates and duration of use:

Other

Yes

No

Please mention any problems with their use and dates and duration of use:

Previous examination

Anamnesis

Sperm examination

Results of 2 – 3 last sperm examinations.

Date

Volume (ml)

Sperm concentration (ml)

Sperm motility (%)

Sperm motility with good progression (%)

Normal sperm morphology (%)

Result of sperm examination

Infertility history

How many years have you been trying to conceive as a couple?

Have you had any previous infertility treatment?

Yes

No

Details

Have you had intrauterine insemination? If YES, please complete the table 1 below

Yes

No

Have you had IVF or any other assisted reproduction technique? If YES, please complete the table 2 below

Yes

No

Have you had frozen embryo transfer (KET)? If YES, please complete the table 3 below

Yes

No

Table 1: Insemination

Month/Year

Used medication

Pregnancy test

Result of pregnancy

Table 2: Artificial Fertilization

Month/Year

Used medication

Number of fertilized oocytes

No. of transferred embryos

Stage of transferred embryos

No. of cryopreserved embryos

Pregnancy test

Result of pregnancy

Table 3: Frozen embryo transfer

1. KET

Month/year

No. of thawing embryos

No. of transferred embryos

Pregnancy test

Result of pregnancy

2. KET

Month/year

No. of thawing embryos

No. of transferred embryos

Pregnancy test

Result of pregnancy

3. KET

Month/year

No. of thawing embryos

No. of transferred embryos

Pregnancy test

Result of pregnancy

Further information which could be useful for the next treatment

Please scan and send us with filled Questionnaire all of your previous examinations and treatment of infertility or bring these documents with you to first visit in our clinic.

Apply medical reports so far

How did you hear about us?

Specify if you have selected "other"

Pre-admission questionnaire

Basic information

Female

Male

Female patient:

Anamnesis

Menstruation

Previous pregnancies

Previous partner

Present partner

Contraception

Previous examination

Male patient:

Anamnesis

Sperm examination

Both patients:

Infertility history

Table 1: Insemination

Table 2: Artificial Fertilization

Table 3: Frozen embryo transfer