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Medical history – woman

    Ovumia Fertinova Tampere:


    The form is sent securely using a safe connection.

    Personal Data

    Name (required)

    Date of birth and age

    Address

    Postal code

    City and country

    Telephone/mobile phone

    E-mail

    Skype address

    Profession

    Marital status (married, living together)

    Spouse’s name

     

    Medical history

    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 and 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.

    Color of the hair

    Color of the eyes

    Color of the skin

    Height

    Ethnical origin


     

    Date and Place


     

      Ovumia Fertinova Helsinki:


      The form is sent securely using a safe connection.

      Personal Data

      Name (required)

      Date of birth and age

      Address

      Postal code

      City and country

      Telephone/mobile phone

      E-mail

      Skype address

      Profession

      Marital status (married, living together)

      Spouse’s name

       

      Medical history

      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 and 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 Fertinova?

      Other observations


      Own characteristics

      To be filled ONLY in connection with donor treatments.

      Color of the hair

      Color of the eyes

      Color of the skin

      Height

      Ethnical origin


       

      Date and Place


       

        Ovumia Fertinova Jyväskylä:


        The form is sent securely using a safe connection.

        Personal Data

        Name (required)

        Date of birth and age

        Address

        Postal code

        City and country

        Telephone/mobile phone

        E-mail

        Skype address

        Profession

        Marital status (married, living together)

        Spouse’s name

         

        Medical history

        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 and 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 Fertinova?

        Other observations


        Own characteristics

        To be filled ONLY in connection with donor treatments.

        Color of the hair

        Color of the eyes

        Color of the skin

        Height

        Ethnical origin


         

        Date and Place