Questionnaire

Please fill in the questionnaire below. This questionnaire will help you to set out your medical history and ask your questions. It will also enable you to have more time at the initial consultation for any further explanations, discussions and any other queries. Please note in the comments, if you would like to beek the initial consultation or prefer to receive the treatment in the fremawork of our transport scheme.

If you have questions, we are ready to answer them in English under +78123363059 09:00-16:00 Moskow time or per e-mail info@clinic.avapeter.com

Information concerning the female partner

Common information

Name

Date of birth

Occupation

Address

Home phone

including country code

Mobile

including country code

E-mail

Individual information

Height (cm)

Weight (kg)

Eye color

Hair color

Blood group

Education

Nationality

Common health

Basic medical disorders

Regular medication

Allergies

Do you smoke?

Surgery in the abdominal area

Gynecology

Surgery in the genital area

Genital infections

Length of menstrual cycle

last period started

Pregnancies in your current relationship

Births, miscarriages, abortions in your current relationship

Pregnancies in your previous relationships

Births, miscarriages, abortions in your previous relationships

Previous fertility treatments

Please describe previous fertility treatments

Information concerning the male partner

Common information

Name

Date of birth

Occupation

Address

Home phone

including country code

Mobile

including country code

E-mail

Individual information

Height (cm)

Weight (kg)

Eye color

Hair color

Blood group

Education

Nationality

Common health

Basic medical disorders

Regular medication

Allergies

Do you smoke?

Surgery in the abdominal area

Andrology/Urology

Genital infections

Pregnancies in former relationships

Semen analysis

Previous fertility treatments

Please describe previous fertility treatments

Both partners

Reason for treatment with donated embryo?

Diagnosis

Comments

Where did you get information about the AVA Peter?

Security code

Fysiologi af den menneskelige forplantning Identifying the cause infertility Infertility treatment Preimplantation genetic diagnosis (PGD) Ægdonation Sperm donation Embryodonation Prenatal diagnostic methods Terminology Frequently asked questions Acknowledgments Press about us Our patients tell their stories (41 unique stories...) Site map	English Deutsch Nederlands Svenska Norsk Русский About the clinic News Specialists Start treatment For Colleagues Trip to St.Petersburg Prices Contacts Home » Embryo adoption » I need embryo adoption » Questionnaire Questionnaire Please fill in the questionnaire below. This questionnaire will help you to set out your medical history and ask your questions. It will also enable you to have more time at the initial consultation for any further explanations, discussions and any other queries. Please note in the comments, if you would like to beek the initial consultation or prefer to receive the treatment in the fremawork of our transport scheme. If you have questions, we are ready to answer them in English under +78123363059 09:00-16:00 Moskow time or per e-mail info@clinic.avapeter.com Information concerning the female partner Common information Name Date of birth Occupation Address Home phone including country code Mobile including country code E-mail Individual information Height (cm) Weight (kg) Eye color Hair color Blood group Education Nationality Common health Basic medical disorders Regular medication Allergies Do you smoke? Surgery in the abdominal area Gynecology Surgery in the genital area Genital infections Length of menstrual cycle last period started Pregnancies in your current relationship Births, miscarriages, abortions in your current relationship Pregnancies in your previous relationships Births, miscarriages, abortions in your previous relationships Previous fertility treatments Please describe previous fertility treatments Information concerning the male partner Common information Name Date of birth Occupation Address Home phone including country code Mobile including country code E-mail Individual information Height (cm) Weight (kg) Eye color Hair color Blood group Education Nationality Common health Basic medical disorders Regular medication Allergies Do you smoke? Surgery in the abdominal area Andrology/Urology Genital infections Pregnancies in former relationships Semen analysis Previous fertility treatments Please describe previous fertility treatments Both partners Reason for treatment with donated embryo? Diagnosis Comments Where did you get information about the AVA Peter? Security code

	egg donation sitemap © AVA-Peter Clinic, 2005—2012. All rights reserved Nevsky pr. 22-24, Saint-Petersburg, Russia, 191186 phone: +7 812 600 7 812 info@clinic.avapeter.com

Our patients tell their stories (41 unique stories...)

Questionnaire

Information concerning the female partner

Common information

Individual information

Common health

Gynecology

Previous fertility treatments

Information concerning the male partner

Common information

Individual information

Common health

Andrology/Urology

Previous fertility treatments

Both partners