Genitrix

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BASIC INFORMATION– FEMALE PARTNER

First name

Address

Last name

City

Date of birth

Zip code

Phone number

Country

Height

E-mail

Weight

Occupation

Family Anamnesis

Has anyone in your family suffered from a (serious) illness? (Cancer, neurological diseases, hereditary diseases, diabetes, high blood pressure, etc.) If so, please let us know below:

Personal Anamnesis

Do you suffer/have you suffered from a (serious) illness? (Cancer, asthma, anemia, diabetes, thyroid disorder, etc.)

Have you ever had an operation? When and what type of surgery was involved (indicate mainly gynecological and abdominal surgeries)?

Do you take medication regularly? If so, please indicate which ones and in what dosage?

Do you have any allergies?

Have you had a genetic analysis (karyotype)?

Have you had a hematological analysis (thrombophilia mutation, factor V Leiden, prothrombin, MTHFR, PAI)?

Gynecological Anamnesis

Age when you got your first period. (e.g. 13 years)

What is the interval between two menstrual cycles? (eg 28 days, from the 1st day of bleeding to the 1st day of the next bleeding).

How long does your menstrual bleeding last? (e.g. 5 days)

Number of pregnancies (year)

Number of births (year)

How long are you trying to conceive with your current partner?

Your last pap smear (cytology examination) (month/year)

Infertility Treatments

Have you undergone any type of treatment? (IUI, IVF, Donated eggs):

Additional information (hormonal profile results – year/month, blood type + RH, etc.)

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