The form is sent securely using a safe connection.
Last name (required)
First names (required)
Personal identity code (required)
Ethnic group: Finnish/something else, please specify
Skin colour: white/black/something else, please specify?
Hair colour: blond/light brown/dark brown/black/red
Eye colour: blue/grey/brown/green
Where did you learn about egg donation? Please list all the places where you have heard or read about it.
Why do you want to donate eggs?
Have you donated eggs before?
Duration of menstrual cycle (days)? Is your cycle regular?
Have you ever had any genital diseases: inflammation/endometriosis/genital cancer/other, please specify.
Which method of contraception do you use: no contraception/condom/contraceptive pill, for how many years/coil, for how many years/male sterilisation, year/female sterilisation, year/other, please specify.
Have you been previously treated for infertility? Where and what kinds of treatments?
Do you have any chronic diseases? (e.g. diabetes, gastric ulcer, arterial hypertension, gastrointestinal disorders, recurrent respiratory tract infections or some other chronic disease)
Have you had any operations?
Have you or your partner been abroad during the last 6 months? If yes, where?
Do you take medications regularly? If yes, please specify.
Smoking: no / yes (number of cigarettes per day)
Units of alcohol (per week, month)1 unit = 12 cl of medium alcohol content wine, 33 cl of cider/beer, 4 cl of spirits
Do you take or have you ever taken or tried drugs? If yes, what and when:
Do you or anyone in your family have any hereditary diseases or deformities? If yes, who and what kind?
Have you or anyone in your family undergone a chromosome analysis or a test for a hereditary disease? If yes, which test or analysis and what was the result?
Does anyone in your family have any of the following diseases and if yes, who: arterial hypertension, diseases of the respiratory system, diabetes, allergy, rheumatic or connective tissue diseases, kidney diseases, epilepsy/multiple sclerosis/other neurological diseases, haemorrhagic disease (e.g. haemophilia, porphyria), muscular dystrophy, cancer, mental disorders (e.g. schizophrenia, bipolar disorder), skin diseases, bone diseases, visual impairment, hearing defects, children born small or stillborn, other?
Other factors that may influence donation of eggs, and possible wishes or comments:
By submitting this form, I consent to the storing of my patient data in Ovumia Oy’s register of patients.
Ovumia Fertinova Tampere +358 20 747 9310 · Ovumia Fertinova Jyväskylä +358 20 747 9313 · Ovumia Fertinova Helsinki +358 20 747 9314
Our office is open Mon-Fri 8.15-15.00.