Medical history

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Personal Data

Name

Date of birth and age

Address

Postal code

City and country

Email address

Phone number

Skype address

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?

Age at the first menstrual period

Length of menstrual cycle. Do you have a regular cycle?

Length of menstrual period

Menstrual pain

Pain during intercourse

Date of last menstrual period

Previous contraception or sterilization. When did you stop contraception, month/year?

If you have performed ovulation tests, on which day the test becomes positive?

Pap test (smear test), year and result

Mammography, year

Births, years (present and past relationships)

Miscarriages, years

Abortions, years

Ectopic pregnancies, years

Genital infections (Chlamydia, Gonorrhea, Condyloma, other)

Genital or abdominal operations

Other operations

Other gynecological diseases

Exposition to radiations or to chemicals, for ex. at work

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 infertility examinations

Previous fertility treatments

Reason for seeking treatment

Where did you obtain information about Ovumia?

Other observations

Own characteristics

To be filled ONLY in connection with donor treatments.

Hair colour

Eye colour

Skin colour

Height

Ethnical origin

Date

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