Sperm analysis questionary

Ovumia Fertinova Tampere:

Last name (required)

First names (required)

ID number (required)

Address

Postal code and post office

Phone number

E-mail

Skype address

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 Helsinki:

Last name (required)

First names (required)

ID number (required)

Address

Postal code and post office

Phone number

E-mail

Skype address

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 Jyväskylä:

Last name (required)

First names (required)

ID number (required)

Address

Postal code and post office

Phone number

E-mail

Skype address

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?)