Name (required)
Date of birth and age
Address
Postal code
City and country
Telephone/mobile phone
E-mail
Profession
Marital status (married, living together)
Spouse’s name
Chronic diseases (ex. diabetes, asthma, gastritis, high blood pressure, bowel diseases, repeated respiratory infections)
Current medications
Other medicines, vitamins or natural supplements
Psychological health
Allergies
Height
Weight
Smoking habits: Yes / No (no. of cigarettes a day). Did you stop smoking? When?
Portions of alcohol (by week or by month)1 portion = 12cl light wine, 33cl sider/beer, 4cl strong alcohol
Use of drugs/tried its use. Did you stop? When?
Number of children and year of birth (present and past relationship)
Previously started pregnancies (miscarriages, abortions, extra-uterine pregnancies)
Genital infections (Chlamydia, Gonorrhea, Condyloma, other)
Genital or abdominal operations
Genital or abdominal traumas
Did the testicles descended at birth normally?
Did puberty start at the same age as your colleagues?
Mumps, at what age?
Exposition to radiations or to chemicals, for ex. at work
Previous contraception method or sterilization year
Do you have sisters or brothers? Do they have children?
Diseases or disabilities running in the family
Since when have you tried to get pregnant? Month, year
Number of intercourses per week or month
Is there any problem in your sexual life?
Previous sperm examinations and results
Previous infertility examinations
Previous fertility treatments
Reason for seeking treatment
Where did you obtain information about Ovumia?
Other observations
To be filled ONLY in connection with donor treatments.
Color of the hair
Color of the eyes
Color of the skin
Ethnical origin
Date and Place
Where did you obtain information about Fertinova?
