Number of years you been trying to conceive?: year(s)
None
Oral contraceptive pill [–]
Hormonal IUD [–]
Copper UID [–]
Contraceptive injection [–]
Other [–]
Total number of pregnancies:
Pregnancies with present partner:
Total number of children:
Number of children with present partner:
Year of birth of your last child:
Rubella ()
Chlamydia ()
Salpingitis ()
Endometriosis ()
Diabetes ()
Epilepsy ()
Thyroid disorder ()
Kidney disease ()
Liver disease ()
Hepatitis B/C/HIV ()
Other operations in the stomach region ()
Ectopic Pregnancy-Surgery ()
Thrombosis or family history of thromoembolic events ()
Other relevant diseases:
Age at first menstruation:
Cycle length:
Cycle duration:
Comment:
No allergies
Medicines you are allergic to:
Other allergies:
No regular medicines
Antiepileptica (, )
Antidiabetics (, )
Levaxin (, )
Antiallergic (, )
Other medicines: (, )
Smoking: No
Smoking: Number of cigarettes per week:
Drinking: No
Drinking: Number of units per week:
Pregnancies with other partner:
Prostatitis ()
Cystic Fibrosis ()
Undescended testis ()
Spinal cord surgery ()
Inguinal hernia / surgery ()
Other medicines (, )