Questionnaire Woman

Basic information

First name

ID card / passport number

E-mail

Surname

Date of birth

Age

Mobile number

Nationality

Address

Anamnesis

How tall are you?

How much do you weigh?

Do you have any illnesses or diseases? (diabetes, cardiopathies, neuropathy, infection)

Yes

No

Details

Do you have any allergies?

Yes

No

Details

Are you on any long term medication?

Yes

No

Details

Have you had an abdominal surgery (e.g., intestinal surgery) in the past?

Yes

No

Details

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:

Gynecological anamnesis

Hysterosalpingography (X ray examination concerning oviduct patency)

Yes

No

Details

Diagnostic or surgical laparoscopy/hysteroscopy

Yes

No

Details

Genetic examination

Yes

No

Details

Physical examinations

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

Pre-admission questionnaire - Woman

Basic information

Anamnesis

Menstruation

Previous pregnancies

Previous partner

Present partner

Contraception

Gynecological anamnesis

Physical examinations