Last name (required)
First names (required)
ID number (required)
Postal code and post office
Spouse’s last name
Spouse’s first names
Spouse’s ID number
Doctor and clinic
Sample taken (date and time)
Sample is: complete/not complete
Taken by: masturbation/some other way
Last ejaculation before this? (days ago)
Why is sperm analysis done: fertility examination/infertility treatment/other reason, what?
Previous sperm analysis? If yes, where?
Previous result: normal/not normal
Do you smoke: no/yes (How many years have you been smoking? How many cigarettes/day?)
Have you had flu or infection during the last three months? (Flu, flu with fever, infection? Infection with fever? How high fever?)
Do you have any chronic disease?
Have you had any medical treatment during the last three months? (What and when?)
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.