Medical history – man

Please fill medical history form before your first appointment with fertility doctor.

Personal Data

First and surname (required)

Social number (required)

Address (required)

Phone number (required)

E-mail address (required)

Nationality (required)

Profession

Marital status (married, living together)

Spouse’s name/ Social number

Appointment time(required)

 

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

Allergies

Height

Weight

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?

Number of children and year of birth (present and past relationship)

Previously started pregnancies (miscarriages, abortions, extra-uterine pregnancies)

Genital infections (Chlamydia, Gonorrhea, Condyloma, other)

Genital or abdominal operations

Genital or abdominal traumas

Did the testicles descended at birth normally?

Did puberty start at the same age as your colleagues?

Mumps, at what age?

Exposition to radiations or to chemicals, for ex. at work

Previous contraception method or sterilization year

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 sperm examinations and results

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

Height

Ethnical origin


 

Date and Place