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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

Personal Data

First and surname (required)

Social number (required)

Birth date (DD/MM/YY) (required)

Address (required)

Phone number (required)

E-mail address (required)

Nationality (required)


Marital status (married, living together)

Spouse’s name/ Social number


Medical history

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

Length of menstrual period

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