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Medical history – man

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)

    Profession

    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

    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