Treatment Programme with Donated Eggs Questionnaire

1 Female partner

2 Male partner

3 Donor requirements

4 Medical history

5 Personal medical history

6 Gynaecological history

7 Infertility history

8 Treatment planning

9 Examinations and consent

Female partner

Surname (as on ID) *

First name *

Date of birth *

Address (street, house no., city, ZIP/postal code, country) *

Phone number *

E-mail *

Height (cm) *

Weight (kg) *

Hair colour

Eye colour

Skin tone

Blood type and Rh factor

Male partner

Surname (as on ID) *

First name *

Date of birth *

Address (street, house no., city, ZIP/postal code, country) *

Phone number *

E-mail *

Height (cm) *

Weight (kg) *

Hair colour

Eye colour

Skin tone

Blood type and Rh factor

Donor requirements

Height (cm)

Weight (kg)

Hair colour

Eye colour

Medical history

Medical history – female partner

Social history: occupation

Family history: illnesses of parents, grandparents, siblings

Countries visited within the last 3 months

Medical history – male partner

Social history: occupation

Family history: illnesses of parents, grandparents, siblings

Countries visited within the last 3 months

Personal medical history

Personal medical history – female partner

Illnesses since childhood

Medication

Surgeries

Injuries

Blood transfusions

Allergies

Thrombosis

Smoking, alcohol, drugs

Any additional information

Personal medical history – male partner

Illnesses since childhood

Medication

Surgeries

Injuries

Blood transfusions

Allergies

Thrombosis

Smoking, alcohol, drugs

Any additional information

Gynaecological history

Menstruation since… years old

Regular/irregular cycle

Cycle length

First day of last menstrual period

Deliveries

Caesarean section

Miscarriage

Termination of pregnancy

Use of hormonal contraception/hormone replacement therapy

Last gynaecological check-up (date)

Last cervical cytology/Pap smear (date and result)

Gynaecological conditions and previous procedures (incl. curettage, revision, hysteroscopy)

Abnormalities of the cervix

Ovarian cysts

Breast conditions

Infertility history

Infertility treatment since year…

Insemination (IUI) cycles and their result

IVF/ICSI cycles and their result

Cycles with donated eggs/embryos and their result

Genetic examination of both partners (karyotype, etc.)

Haematological and immunological examination of the female partner

Treatment planning

When would you like to start treatment?

How did you hear about ReproGenesis?

Essential examinations before treatment

Male partner

Semen analysis
STDs (Hepatitis B incl. HBsAG, anti-HBc total, Hepatitis C, Syphilis, HIV 1, HIV 2) – this examination will be carried out at our clinic

Female partner

TSH, fT4, Prolactin

This overview of examinations is for your guidance. Examinations may be carried out at our clinic. Results must not be older than 3 months. Further examinations may be requested by the doctor based on your medical history.

Thank you for your time! 🙂

* Required field

Before you start

The questionnaire has 9 steps, and you can freely move between them
A step in progress cannot be saved – we recommend filling in the questionnaire in one sitting
All data is kept confidential and protected