Patient’s Questionnaire

After analyzing your information we will send you back a proposal for further procedures and therapeutical possibilities. Copy the file to your computer, fill in the questionnaire, save it to your computer and send it back to an email address:

Information concerning both partners

  1. Infertility duration (number of years trying to reach pregnancy)
  1. Number of pregnancies with current partner
  2. number of pregnancies:
  3. number of deliveries:
  4. number of miscarriages:
  5. number of extrauterine pregnancies:
  1. Number of pregnancies with any previous partners
  2. number of pregnancies:
  3. number of deliveries:
  4. number of miscarriages:
  5. number of extrauterine pregnancies:
  1. Therapy by means of methods of assisted reproduction in the past:
  2. Intrauterine insemination (indicate last 4 inseminations)
  1. Assisted reproduction – artificial fertilization

(IVF, ICSI, oocyte donation, PGD)

  • month and year:
  • medicines used:
  • number of oocytes:

-own

-donated

  • number of fertilized oocytes:
  • IVF or ICSI
  • number of embryos transferred:
  • number of embryos cryopreserved:
  • course of embryo transfer:
  • Pregnancy:
  • Comments:
  1. Transfer of embryos defrosted:
  • Month/Year:
  • Number of embryos defrosted:
  • Number of embryos transferred:
  • Pregnancy:

Information on the woman:

Age:

Medical History:

  1. Cycle/period duration: (e.g. 28-29/5):
  2. Weight:
  3. Height :
  4. Smoking habits (Cigarettes/day):
  5. General medical history:
  1. Personal
  1. Do you suffer from any illness which might impair your health during pregnancy (diabetes, cardiopathies, neuropathy)?
  1. Surgery, especially on reproductive organs (ovaries, oviducts, uterus) and/or appendectomy:
  1. Allergies – especially to medicines (medicine designation)
  1. Medicines administered currently:
  1. Gynaecological
  1. Deliveries:
  2. Miscarriages – abortions:
  1. Examinations performed during diagnostics and therapy of infertility
  1. FSH, LH and oestradiol levels between cycle days 1-4

(Please give the most accurate data, if possible)

2. AMH - Antimullerian hormone (Please give the most accurate data, if possible)

  1. Prolactin level (Please give the most accurate data, if possible)
  1. Transvaginal ultrasound (presence of cysts, myomas, polyps, …)

-Have you undergone hysterosalpingography? (X-ray examination concerning oviduct patency) or laparoscopy. Results?

-Uterus:

-Oviducts:

  1. Have you undergone a post-coital test in order to find the presence of mobile spermatozoa in mucus? What was the outcome (normal or abnormal?)
  1. Have you undergone a genetic examination? (What was the outcome?)
  1. Further examinations and comments

Information on the man

Age:

Medical history:

a. Family: Have any genetic disorder or infertility problems occurred in your family?

b. Personal:

  1. Did you suffer from mumps during adolescence?
  2. Do you have an inborn defect of the genitals (genesis vas deferens, testicle descensus …) ?
  3. Have you suffered from any genital injury or varicocele?
  4. Allergies: especially to medicines (medicine designation)
  5. What medicines do you take at present?
  6. Do you smoke? Number of cigarettes/day.

c. Obstetric

deliveries and miscarriages with your previous partner:

Examinations performed during diagnostics and therapy of your infertility

  1. Outcomes of the 2-3 latest sperm characteristics

Date:

Volume (in ml):

Sperm concentration /ml):

Sperm motility (%):

Sperm motility with good progression (%):

Normal sperm morphology (%):

  1. FSH, LH, PRL, testosterone levels in blood:

c.Genetic examination (karyotype):

Therapy up to now:

a. Administered medicines:

b. Surgeries:

Further:

Personal data:

Name and Surname:

Telephone:

E-mail:

Please kindly return this questionnaire to an email address: