Medical history
Have you been fully vaccinated (2 doses) of COVID-19 and when?
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Have you had COVID-19 and when?
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Current medications
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Other medicines, vitamins or natural supplements
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Psychological health
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Allergies
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Smoking habits: Yes / No (no. of cigarettes a day). Did you stop smoking? When?
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Use of drugs/tried its use. Did you stop? When?
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Age at the first menstrual period
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Menstrual cycle length
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Bleeding days
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Menstrual pain
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Pain during intercourse
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Date of last menstrual period
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Previous contraception or sterilization. When did you stop contraception, month/year?
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If you have performed ovulation tests, on which day the test becomes positive?
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Pap test (smear test), year and result
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Mammography, year
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Miscarriages, years
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Abortions, years
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Ectopic pregnancies, years
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Genital and abdominal operations
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Other operations
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Other gynecological diseases
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Exposition to radiations or to chemicals, for ex. at work
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Do you have sisters or brothers? Do they have children?
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Diseases or disabilities running in the family
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Since when have you tried to get pregnant? Month, year
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Number of intercourses per week or month
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Is there any problem in your sexual life?
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Previous infertility examinations
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Previous fertility treatments
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Reason for seeking treatment
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Where did you obtain information about Nova Vita?
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Other observations
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