Questionnaire

Fertility Seminars

Main Questionnaire

Please, don't forget to fill the fields noted by an asterisk *

Information about female partner

General information

Full name

Date of birth

Nationality

Educational level

Occupation

Country of residence

Address

Home phone

including country code

Mobile

including country code

E-mail *

How would you prefer to be contacted?

Medical information

Height (cm)

Weight (kg)

Eye colour

Hair colour

Blood group

Please describe in detail any medical conditions you have

Do you take any medication regularly?

Do you have any allergies?

Do you smoke?

If so, how many cigarettes per day?

Have you had surgery in the abdominal area?

If yes, please provide detailed information about diagnosis and operation

Have you had any genital or urinary infections?

How long is your menstrual cycle?

When was the first day of the last menstruation?

Do you take any hormonal medication?

Have you been pregnant in this relationship?

Please describe the outcomes (births/miscarriages/terminations)

Have you been pregnant in previous relationships?

Please describe the outcomes (births/miscarriages/terminations)

Please describe any fertility investigations and treatments you have had

Your partner

Please select

Information about the female partner

General information

Full name

Date of birth

Nationality

Educational level

Occupation

Country of residence

Address

Home phone

including country code

Mobile

including country code

E-mail

How would you prefer to be contacted?

Medical information

Height (cm)

Weight (kg)

Eye colour

Hair colour

Blood group

Please describe in detail any medical conditions you have

Do you take any medication regularly?

Do you have any allergies?

Do you smoke?

If so, how many cigarettes per day?

Have you had surgery in the abdominal area?

If yes, please provide detailed information about diagnosis and operation

Have you had any genital or urinary infections?

How long is your menstrual cycle?

When was the first day of the last menstruation?

Do you take any hormonal medication?

Have you been pregnant in this relationship?

Please describe the outcomes (births/miscarriages/terminations)

Have you been pregnant in previous relationships?

Please describe the outcomes (births/miscarriages/terminations)

Please describe any fertility investigations and treatments you have had

Own comment

Information about the male partner

General information

Full name

Date of birth

Nationality

Educational level

Occupation

Country of residence

Address

Home phone

including country code

Mobile

including country code

E-mail

How would you prefer to be contacted?

Medical information

Height (cm)

Weight (kg)

Eye colour

Hair colour

Blood group

Please describe any medical conditions you have

Do you take any medication regularly?

Do you have any allergies?

Do you smoke?

If so, how many cigarettes per day?

Have you had surgery in the abdominal area?

If yes, please provide detailed information about diagnosis and operation

Have you had any genital or urinary infections?

Have there been any pregnancies in your previous relationships?

Please describe the results of any semen analysis you have had

Please describe any fertility investigations an treatments you have had (if different or additional to the information provided by your partner, f.E. IVF in your previous relationship)

Your expectations from the treatment at our clinic

What are your reasons for seeking treatment with donated eggs?

Would you like to visit us for the Initial consultation?

What aspects of treatment are the most important for you?

you may choose one, several, all options or none

Your attitude to the process of egg donor selection

Do you want to choose your egg donor yourself from a detailed data base ?

Do you want your AVA-Peter Doctor to match a donor for you?

Do you want to receive as much as possible information about your egg donor?

Do you want to receive only very little information about your egg donor?

Please mark which criteria are important for you when choosing your egg donor

you may choose one, several, all options or none

If you would like to add anything about your egg donor expectations, please write below

Other information

How did you find out about AVA-Peter?

forum (which one? Please fill in)

other source (which one? Please fill in)

If you have any questions that are not answered by information on the AVA-Peter website, please give details below

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