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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
Thank you in advance, your Nova Vita Clinic

    All fields are required.

    Personal Data

    First and surname

    Social number

    Date of birth (DD.MM.YY, e.g. 25.05.90) and age




    Phone number

    E-mail address



    Marital status (married, living together)

    Spouse’s name/ Social number


    Medical history

    Have you been fully vaccinated (2 doses) of COVID-19 and when?

    Have you had COVID-19 and when?

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

    Current medications

    Other medicines, vitamins or natural supplements

    Psychological health




    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 (Chlamydia, Gonorrhea, Condyloma, other)

    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

    Reason for seeking treatment

    Where did you obtain information about Nova Vita?

    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


    Ethnical origin


    Date and Place

    Read more about the processing of personal data by Nova Vita Kliinik AS from Nova Vita's Privacy Policy.