Medical history – fertility check-up

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Choose clinic *

Personal data

Name *

Finnish personal ID (or date of birth) *

Address *

Postal code *

City *

e-mail *

Phone *

Profession

Relationsihip since ( year) since you were last in a relationship ?

Medical history

Height

Weight

Chronic diseases (ex. diabetes, asthma, gastritis, high blood pressure, bowel diseases, repeated respiratory infections)

do you use birth control if so what?

Current medications

Other medicines, vitamins or natural supplements

Psychological health

Allergies

Habits

Do you exercise, how often and what?

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

Do you use nicotine products?, What?, How much?. Have you finished when?

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

Menstrual cycle

Length of menstrual cycle. Do you have a regular cycle?

Age at the first menstrual period

Length of menstrual period

Menstrual pain

Pain during intercourse

Date of last menstrual period

Pap test (smear test), year and result

Mammography, year

Births, years (present and past relationships)

Miscarriages, years

Abortions, years

Ectopic pregnancies, years

Genital infections (Chlamydia, Gonorrhea, Condyloma, other)

Genital or abdominal operations

Other gynecological diseases

Where did you find out about Ovumia?

Other considerations

Date

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