Health record - Female

Please fill out the health form before your first 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 information

First name *

Last name *

Date of birth *

Personal ID *

Street *

Building No. *

Apartment No. *

Zip code *

City *

Phone *

Email *

Nationality *

Occupation *

Marital status *

Spouse’s/partner’s name/ID number *

May the attending physician review your digital medical record before the appointment? *

Reason for the appointment? *

Medical information

Height/Weight *

Blood type/Rh factor *

Do you have any allergies? *

Do you take medication daily? *

Do you take vitamins/natural supplements? *

Questions related to infertility

Since what year have you been trying to conceive? *

Have you undergone infertility testing? *

Have you previously received fertility treatment? *

If you have taken an ovulation test, on which day of your cycle was the test positive? *

Do you have problems with your sex life? *

How many times a week or a month do you have sexual intercourse? *

Length of your menstrual cycle in days? *

How many days does your period last? *

Do you experience menstrual cramps? *

Do you experience menstrual pain? *

Start date of your last menstrual period? *

Have you ever given birth? (how many/year?) *

Have you had any complications related to childbirth? *

Have you had any miscarriages? *

Have you ever had an abortion? *

Have you ever had an ectopic pregnancy? *

Gynecological conditions *

What types of birth control have you used? *

When did you stop using contraception? *

When was your last Pap test? *

Have you had a mammogram? *

Current and past medical conditions

Chronic illnesses *

Infectious diseases *

Sexually transmitted diseases *

Hereditary diseases *

Have you ever had surgery? *

Have you ever received a blood transfusion? *

Family history

Have any close relatives had, for example, thrombosis, stroke, heart attack, endometriosis, diabetes, or thyroid disorders? *

Do you know when your mother went through menopause? *

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

Harmful habits and other risk factors

Are you exposed to radiation or chemicals? *

Smoking, yes/no (how many cigarettes per day?) Have you quit smoking? *

Alcohol consumption *

Drug use/have you tried drugs? Have you stopped? *

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

I confirm that all of the above information is correct. If my contact information (name, address, phone number, email) changes, I will notify the Clinic immediately. *

Date *

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