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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
Thank you in advance, your Nova Vita Clinic

All fields are required.

Medical history – man

Personal Data

(DD.MM.YYYY, e.g. 25.05.1990)
(married, living together)

Medical history

(ex. diabetes, asthma, gastritis, high blood pressure, bowel diseases, repeated respiratory infections)
1 portion = 12cl light wine, 33cl sider/beer, 4cl strong alcohol
(present and past relationship)
(miscarriages, abortions, extra-uterine pregnancies)
(Chlamydia, Gonorrhea, Condyloma, other)

Own characteristics

To be filled ONLY in connection with donor treatments.
AS Nova Vita Clinic´s general conditions for the provision of healthcare services

AS Nova Vita Clinic´s Privacy Policy.