On-line Questionnaire
The medical data you will provide bellow, will be available to authorized physicians of our clinic only. The data are part of your medical record.

You may use the electronic form (provided here) or download the form in PDF format and mail it to us.
Identification of a couple
Woman’s name
Woman’s surname
Date of Birth
The field is empty
The field is empty
The field is emptyInvalid format (dd.mm.yyyy)
Man’s name
Man’s surname
Date of Birth
The field is empty
The field is empty
The field is emptyInvalid format (dd.mm.yyyy)
Contact
Adress:
The field is empty
E-mail 1:
The field is emptyInvalid format
E-mail 2:
Invalid format
tel. No. 1:
tel. No. 2:


Woman
Family anamnesis
Please tick the appropriate answer and mention who suffers from disease, specify the details
Diabetes:
Yes No
Hypertension:
Yes No
Heart and vacular diseases:
Yes No
Congenital defects:
Yes No
Malignancy:
Yes No
breast uterus ovary other
Others:
Personal anamnesis
Please tick the appropriate answer and specify the details
Diabetes:
Yes No
Hypertension:
Yes No
Heart and vacular diseases:
Yes No
Congenital defects:
Yes No
Trombosis:
Yes No
Hepatitis:
Yes No
A B C other
Malignancy:
Yes No
breast uterus ovary other
Others:
Other informations
Do you have an allergy?
Yes No
What are you allergic to?
Are you allergic to any medication?
Do you smoke?
Yes No
Cigerettes per day?
Do you use any medications regularly?
Yes No
What for?
What medication do you use?
Height:
Weight (kg):
Blutgruppe:
Findings should be later documented
Gynaecological anamnesis
At what age did your menses begin?
Age
Specify the shortest and the longest period from the first day of your bleeding until the beginning of next bleeding and the shortest and the longest period of your menses.
Cyclus: - / -
Pregnancy
Delivery in year:
The same partner: Yes No
Completion:
Delivery in year:
The same partner: Yes No
Completion:
Delivery in year:
The same partner: Yes No
Completion:
Delivery in year:
The same partner: Yes No
Completion:
Miscarriage in year:
The same partner: Yes No
Completion:
Miscarriage in year:
The same partner: Yes No
Completion:
Miscarriage in year:
The same partner: Yes No
Completion:
Miscarriage in year:
The same partner: Yes No
Completion:
Abortion in year:
The same partner: Yes No
Completion:
Abortion in year:
The same partner: Yes No
Completion:
Abortion in year:
The same partner: Yes No
Completion:
Extrauterine pregnancy:
The same partner: Yes No
Completion:
Extrauterine pregnancy:
The same partner: Yes No
Completion:
Gynaecological diseases
Please tick the appropriate answer and specify if necessary
Endometriosis:
Yes No
Pelvic inflammatory disease:
Yes No
Cysts:
Yes No
Brest disease:
Yes No
Others:
Gynaecological operation:
Yes No
Other gynaecological operation:
Yes No
Other gynaecological operation:
Yes No
Other gynaecological operation:
Yes No
Completion:


Man
Family anamnesis
Please tick the appropriate answer and mention who suffers from disease, specify the details
Diabetes:
Yes No
Hypertension:
Yes No
Heart and vacular diseases:
Yes No
Congenital defects:
Yes No
Malignancy:
Yes No
Others:
Personal anamnesis
Please tick the appropriate answer and specify the details
Diabetes:
Yes No
Hypertension:
Yes No
Heart and vacular diseases:
Yes No
Congenital defects:
Yes No
Trombosis:
Yes No
Hepatitis:
Yes No
A B C other
Malignancy:
Yes No
Others:
Other informations
Do you have an allergy?
Yes No
What are you allergic to?
Are you allergic to any medication?
Do you smoke?
Yes No
Cigerettes per day?
Do you use any medications regularly?
Yes No
What for?
What medication do you use?
Height:
Weight (kg):
Blood group:
Findings should be later documented


Infertility
Please tick what part was examined and specify if necessary
Duration in months:
Tubal patency test Laparoscopy:
Yes No
Findings:
Tubal patency test X-ray:
Yes No
Findings:
Tubal patency test by using different method:
Yes No
What method was used?
 
Findings:
Evidence of ovulation US foliculometry:
Yes No
Findings:
Evidence of ovulation by using different method:
Yes No
What method was used?
 
Findings:
Executed Tests
FSH between the 2nd and the 5th day of a cycle:
Yes No
Value:
LH between the 2nd and the 5th day of a cycle:
Yes No
Value:
TSH:
Yes No
Value:
Prolactin:
Yes No
Value:
Progesteron:
Yes No
Value:
Others:
STD Woman
HIV anti HIV 1,2 if possible Ag p24:
Yes No
Value:
Findings should be later documented
hepatitis B HbSAg:
Yes No
Value:
Findings should be later documented
hepatitis B if possible anti HbC IgM:
Yes No
Value:
Findings should be later documented
hepatitis C anti HCV antibodies:
Yes No
Value:
Findings should be later documented
Lues:
Yes No
Value:
Findings should be later documented
STD Man
HIV anti HIV 1,2 if possible Ag p24:
Yes No
Value:
Findings should be later documented
hepatitis B HbSAg:
Yes No
Value:
Findings should be later documented
hepatitis B if possible anti HbC IgM:
Yes No
Value:
Findings should be later documented
hepatitis C anti HCV antibodies:
Yes No
Value:
Findings should be later documented
Lues:
Yes No
Value:
Findings should be later documented
Spermanalysis
In Year:
Normal Minor pathological Pathological Major pathological Azoospermie
In Year:
Normal Minor pathological Pathological Major pathological Azoospermie
In Year:
Normal Minor pathological Pathological Major pathological Azoospermie
In Year:
Normal Minor pathological Pathological Major pathological Azoospermie
Genetic examination:
Yes No
Imunologic examination:
Yes No


Actual history of infertility treatment
Intrauterine insemination (IUI) without ovarian stimulation:
Yes No
How many times
Intrauterine insemination (IUI) with ovarian stimulation - Clomid:
Yes No
How many times
Intrauterine insemination (IUI) with ovarian stimulation - gonadotropins:
Yes No
How many times
IVF cyclus:
Yes No
In Year
IVF cyclus:
Yes No
In Year
IVF cyclus:
Yes No
In Year
IVF cyclus:
Yes No
In Year
IVF cyclus:
Yes No
In Year
Completion: