Please describe us your Medical History as well as your previous Fertility Treatments so our Fertility Specialists can advise you on the most suitable Treatment Protocol.

To download the questionnaire and fill it in at your convenience, please CLICK HERE


Firstname (as in your ID or passport)
Surname/Family Name (as in your ID or passport)
 

Date of Birth

Home Address

Country

Telephone Home Landline

Telephone Mobile

 

E-mail Address

Verify E-mail Address

 

Profession

Marital Status

 

Fertility History - Female Patient

Please describe your previous fertility history, including any pregnancies, miscarriages, previous fertility treatments & their outcomes. Please give dates.
For fertility treatments please give details of the protocol (the medications and doses used, the duration of stimulation) and the number of eggs retrieved, and the number of embryos available and transferred.
Please note if you experienced any unusual symptoms around implantation time (fever, sore throat, joint pain, skin rashes etc) and if you bled before the test date on any IVF cycles.


Please attach in a separate document if easier.

Further Questions - Female Patient

Do you have menstrual cycles/periods ?

Are these cycles regular ?

How long does your cycle last (from one bleeding to the next)?

How long does the bleeding usually last ?

Describe the bleeding – is it profuse and red? Does it stop and start abruptly or is there brown spotting before the period or after the period?

When do expect your next cycle to start ?

Have you had a hysteroscopy, aquascan or laporoscopy ? if so, please give the date and the findings.

 

Do you take any medication regularly, including vitamins and supplements? (please list).

Have you ever been diagnosed with any kind of immune problems?

Have you had your thyroid hormones tested? Please list TSH, FT4, antithyroid antibodies here.

Please list any recent results of FSH, LH, prolactin, AMH tests etc

Have you ever been checked for clotting (thrombophilia) problems ? If so, what were the results ?

Have you ever been checked for Chlamydia (PCR) ? If so, what were the results ?

Have you ever been checked for karyotyping? What were the results?

Have you ever been diagnosed with a viral infection (herpes, shingles, cold sores , HPV etc)?

Please list any other fertility related test results with dates

Please list any other health issues, including allergies and any previous operations that we should be aware of.

Please give your height, weight and BMI

Please indicate your ethnic origin

Please give your hair colour and eye colour
Please give your blood group if known



Husband / Partner - Health Information (Please fill it on where there is a Male Partner)


First Name (as in your ID or passport)
Last Name (as in your ID or passport)

Date of Birth

Occupation
Have you had any children ?

Have you had any sperm analysis undertaken ? If so please list details.

Have you ever been checked for karyotyping ? If so, please list results.

Have you ever been checked for cystic fibrosis gene mutations? If so, please list results.

Please list any other health issues, including allergies and any previous operations that we should be aware of.

Do you take any drugs (including vitamins and supplements) regularly ? Please list here:

Please give your height, weight and BMI

Please indicate your ethnic origin

Please give your hair colour and eye colour
Please give your blood group if known

Questions

Please list here any initial questions or concerns you may have regarding any treatment.

Please also note that for your initial consultation we would like you to bring:

1. HIV 1 + 2 test – dated in last 6 months*

2. Syphilis test (VDRL or RPR) – dated in last 6 months*

3. Hepatitis B (HbsAg) test – dated in last 6 months*

4. Hepatitis C (HCV) test– dated in last 6 months*

5. Cardiogram / ECG test report– dated in last 6 months (required only for patients intending Egg Collection or Surgical Sperm Retrieval)**

6. Marital status certificate we need to have a copy of this for our files as following. **

 

Married couples

Marriage certification

Single

A valid certification signed by you in presence of a notary that you are undergoing IVF treatment declared a single lady with anonymous sperm donation responsible for the child / children conceived

Partnership

A valid certification signed by both parties in presence of a notary that you are both undergoing IVF treatment declared / as partners responsible for the child / children conceived

7. Passport

*If you do not have items 1-4, we can arrange to do these tests for you for €110 per person.

For married and unmarried couples, regardless of whether sperm donation will be used, both partners must show proof of testing as this is a legal requirement.

**If you need us to arrange the ECG for you, please let us know.

***If you need us to arrange the relevant certification that applies for single ladies and couples in partnership we may organize this with a local notary at the cost of 75 euros.