• Information about the woman
    [Max 10Mb]
  • Previous contraceptives
    Previous pregnancies
  • Previous and current diseases
  • Menstrual cycle
    info
    info
    Allergies
  • Regular medicines
    Lifestyle factors
  • Information about the partner
    Partner: Involvement in previous pregnancies
    (Max 10Mb)
  • Partner: Previous and current diseases
  • Partner: Allergies
    Partner: Lifestyle factors
  • Partner: Regular medicines
  • Marketing Survey

    In order to better understand our clients we kindly ask you to provide us the following information.

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    Why did you choose us for your fertility treatment?
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    Information about the woman
    Previous contraceptives

    None

    Oral contraceptive pill []

    Hormonal IUD []

    Copper UID []

    Contraceptive injection []

    Other []

    Previous pregnancies

    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:

    Previous and current diseases

    None

    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:

    Menstrual cycle

    Age at first menstruation:

    Cycle length:

    Cycle duration:

    Comment:

    Allergies

    No allergies

    Medicines you are allergic to:

    Other allergies:

    Regular medicines

    No regular medicines

    Antiepileptica (, )

    Antidiabetics (, )

    Levaxin (, )

    Antiallergic (, )

    Other medicines: (, )

    Lifestyle factors

    Smoking: No

    Smoking: Number of cigarettes per week:

    Drinking: No

    Drinking: Number of units per week:

    Partner: Previous and current diseases

    Chlamydia ()

    Prostatitis ()

    Diabetes ()

    Cystic Fibrosis ()

    Epilepsy ()

    Undescended testis ()

    Thyroid disorder ()

    Spinal cord surgery ()

    Kidney disease ()

    Hepatitis B/C/HIV ()

    Liver disease ()

    Inguinal hernia / surgery ()

    Other relevant diseases:

    Partner: Allergies

    No allergies

    Medicines you are allergic to:

    Other allergies:

    Partner: Lifestyle factors

    Smoking: No

    Smoking: Number of cigarettes per week:

    Drinking: No

    Drinking: Number of units per week:

    Partner: Regular medicines

    No regular medicines

    Antiepileptica (, )

    Antidiabetics (, )

    Levaxin (, )

    Antiallergic (, )

    Other medicines (, )

    Confirm:
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