Electronic patient information form

First name

Family name

Adress

Zip Code

City

Country

Personnumer or Date of birth (6 digits, for example 280571)

Phone no. daytime

Cell phone no.

E-mail

May we retrieve blood test results in “laboratorie portalen”? (only relevant if you have a Danish CPR number)

Marital status

Your partners gender

General information

How long have you tried to become pregnant?

Allergies?

What?

Medication

Name and Dose

Folic acid

Herbal Medicine

Name and Dose

Tobacco?

No. of cigarettes per day

Alcohol?

No. of glasses per week

Are you fit and healthy?

Have you had any surgery?

When and for what?

Hereditary diseases?

What?

Have you ever had a thrombosis?

When and where?

Occupation

Gynaecological Information

Do you have regular periods?

My last period started

Average lengths of your menstrual cycle in days (including menstruation)

When did you last time have a PAP smear from your cervix?

Have you had a pathological smear?

Year

Have you had a conic sectioning of the cervix?

Year

Have you had a Chlamydia infection?

Year

When was you last tested for Chlamydia?

Have you had a pelvic inflammation?

Year?

Do you have strong menstrual cramps?

Do you have Endometriosis?

Have you had investigated the passage of your Tubes?

When?

What Method?

Result

No. of Pregnancies

What years?

No. of Births

Years for births

No. of Abortions

No. of Ectopic Pregnancies

Have you obtained pregnancies with your actual partner?

Do you have children with your actual partner?

Have you been in fertility treatment before?

When and what treatment?

Have you had German Measles?

Are you vaccinated against German Measles?

Do you have results of the statutory tests for HIV and Hepatitis?

Date of Analyses?

HIV

Anti-HBc

HBsAg

Anti-HCV

Is the laboratory accredited according to DIN EN 15189 or 17025

Your height (cm)

Your weight (kilogram)

About partner – information

About partner

First name

Family name

Address

Zip Code

City

Country?

Personnumer or Date of birth

Phone no. daytime

Cell phone no.

E-mail

May we retrieve blood test results in “laboratorie portalen”? (only relevant if you have a Danish CPR number)

General information – Male

Allergies?

What?

Medication

Name and Dose

Folic acid?

Herbal Medicine?

Name and Dose

Tobacco – Male partner

No. of cigarettes per day

Alcohol

No. of glasses per week

Are you fit and healthy?

Have you had any surgery?

Hereditary diseases?

What?

Have you ever had a thrombosis?

When and where?

Occupation

Andrology – Male

Do you have children with another woman?

Number?

Have you have made a semen analysis?

Results?

Have you had any Chlamydia infections?

Year?

Have you had other infections of the urinary tract or testicles?

Year?

Have you been operated for undescended testicles?

Year?

Have you had any operations in your testicles?

When and why?

Have you had any damage to your testicles?

Year?

Do you have any genital malformations?

What kind?

Have you been operated for hernia?

Year?

Do you have results of the statutory tests for HIV and Hepatitis?

Date of Analyses?

HIV

Anti-HBc

HBsAg

Anti-HCV

Is the laboratory accredited according to DIN EN 15189 or 17025

Your height (cm)

Your weight (kilogram)

General information – Female

How long have you tried to become pregnant?

Allergies?

What?

Medication

Name and Dose

Folic acid

Herbal Medicine

Name and Dose

Tobacco?

No. of cigarettes per day

Alcohol?

No. of glasses per week

Are you fit and healthy?

Have you had any surgery?

When and for what?

Have you ever had a thrombosis?

When and where?

Hereditary diseases?

What?

Occupation

Gynaecological Information – Female partner

Do you have regular periods?

My last period started

Average lengths of your menstrual cycle in days (including menstruation)

When did you last time have a PAP smear from your cervix?

Have you had a pathological smear?

Year

Have you had a conic sectioning of the cervix?

Year

Have you had a Chlamydia infection?

Year

When was you last tested for Chlamydia?

Have you had a pelvic inflammation?

Year

Do you have strong menstrual cramps?

Do you have Endometriosis?

Have you had investigated the passage of your Tubes?

When?

What Method?

Result

No. of Pregnancies

No. of Births

Years for births

No. of Abortions

No. of Ectopic Pregnancies

Have you obtained pregnancies with your actual partner?

Do you have children with your actual partner?

Have you been in fertility treatment before?

When and what treatment?

Have you had German Measles?

Are you vaccinated against German Measles?

Do you have results of the statutory tests for HIV and Hepatitis?

Date of Analyses?

HIV

Anti-HBc

HBsAg

Anti-HCV

Is the laboratory accredited according to DIN EN 15189 or 17025

Your height (cm)

Your weight (kilogram)

Captcha

Electronic patient information form

Questionnaire regarding your Health

General information

Gynaecological Information

About partner – information

About partner

General information – Male

General information – Male

Andrology – Male

General information – Female

General information – Female

Gynaecological Information – Female partner

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