questionnaire

IVF Questionaire

questionnaire

Fill out our questionnaire and help us advise you
on the most suitable Treatment Protocol

Download Questionnaire in WORD
Download Questionnaire in PDF

    First name (as in your ID or passport)
    Surname/Family Name (as in your ID or passport)
    Date of Birth (mm/dd/yyyy
    Father's first name
    Mother's first name
    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 outcomesf 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
    Telephone
    Email
    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.
    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
    Have you ever been checked for karyotyping ? If so, please list results.

    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

    Please also note that according to the Greek law it is required that you bring before your medical treatment (IVF-IUI etc.) the below:
    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 and Anti-HBc) 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 lady

    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
    1, 2, 3 & 4 are also required when the male partner wishes to cryopreserve semen.
    *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.
    ***We will arrange the relevant certification that applies for single ladies and couples in partnership with a local notary at the cost of 100 euros.
    **** It is strongly suggested for:
    All women under 35 years old, a recent breast ultrasound
    All women over 35 years old, a recent mammography
    ***** It is strongly advised to secure travel medical insurance before your treatment.
    A highly recommended option is through www.medicaltravelshield.com