Medical history – woman

Please fill medical history form before your first appointment with fertility doctor.

The medical history is an informative form for the doctor before the first appointment.
The medical history form reaches us through a secured system.
Please fill your medical history form accurately and correctly
All fields are required.

Thank you in advance, your Ovumia Tallinn (Nova Vita Clinic)

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 (married, living together) *

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? *

Age at the first menstrual period *

Menstrual cycle length *

Bleeding days *

Menstrual pain *

Pain during intercourse *

Date of last menstrual period *

Previous contraception or sterilization. When did you stop contraception, month/year? *

If you have performed ovulation tests, on which day the test becomes positive? *

Pap test (smear test), year and result *

Mammography, year *

Births, years (present and past relationships) *

Miscarriages, years *

Abortions, years *

Ectopic pregnancies, years *

Genital infections *

Genital and abdominal operations *

Other operations *

Other gynecological diseases *

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

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 infertility examinations *

Previous fertility treatments *

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 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. *

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

Date *

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