Health record - Male

Please fill out the health record before your initial appointment.

The health form provides information to your treating physician before your visit.
The health form is sent to us via a secure system.
Please fill out the health form accurately and correctly.

All fields are required.

Thank you in advance, Ovumia Tallinn

Personal Data

First name ( as in passport) *

Surname ( as in passport) *

Date of birth and age *

Social number *

Address *

City *

Country *

Phone number *

E-mail address *

Nationality *

Profession *

Marital status *

Spouse’s name/ Social number *

Reason for booking consultation? *

Medical history

Chronic diseases *

Current medications *

Other medicines, vitamins or natural supplements *

Psychological health *

Allergies *

Height *

Weight *

Smoking habits: Yes / No (no. of cigarettes a day). Did you stop smoking? When? *

Portions of alcohol (by week or by month) 1 portion = 12cl light wine, 33cl sider/beer, 4cl strong alcohol *

Use of drugs/tried its use. Did you stop? When? *

Number of children and year of birth *

Previously started pregnancies *

Genital infections *

Genital and abdominal operations *

Genital or abdominal traumas *

Did the testicles descended at birth normally? *

Did puberty start at the same age as your age-mates? *

Mumps, at what age? *

Exposition to radiations or to chemicals, for ex. at work *

Previous contraception method or sterilization year *

Do you have sisters or brothers? Do they have children? *

Diseases or disabilities running in the family *

Since when have you tried to get pregnant? Month, year *

Number of intercourses per week or month *

Is there any problem in your sexual life? *

Previous sperm examinations and results *

Previous infertility examinations *

Previous fertility treatments *

Where did you obtain information about Ovumia Tallinn? *

Other observations *

Own characteristics

To be filled ONLY in connection with donor treatments.

Color of the hair

Color of the eyes

Color of the skin

Height

Ethnical origin

I have read and agree to the privacy policy of Ovumia Tallinn / AS Nova Vita Clinic *

I confirm that all the above information is correct. If my contact details (name, address, phone number, e-mail) change, I will inform the Clinic immediately. *

Date *

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