First and surname (required)
Social number (required)
Phone number (required)
E-mail address (required)
Marital status (married, living together)
Spouse’s name/ Social number
Chronic diseases (ex. diabetes, asthma, gastritis, high blood pressure, bowel diseases, repeated respiratory infections)
Other medicines, vitamins or natural supplements
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
Length of menstrual cycle. Do you have a regular cycle?
Length of menstrual period
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
Births, years (present and past relationships)
Ectopic pregnancies, years
Genital infections (Chlamydia, Gonorrhea, Condyloma, other)
Genital and abdominal 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?
To be filled ONLY in connection with donor treatments.
Color of the hair
Color of the eyes
Color of the skin
Date and Place
Our office is open Mon-Fri 8.30-16.30.