Dear clients,

As part of your forthcoming treatment we have prepared the following questionnaire, which serves to facilitate the communication between you and our physician. Please complete the questionnaire by filling out all the required data. Do not hurry, take your time. The information in the questionnaire is very important and will help the physician with designing the best treatment option for you. The questionnaire also includes your identification data, which is required to draft the Application for Treatment.

This site is secured via encryption and an SSL certificate, which provides communication between you and the data server. The data is stored only in the database of Reprofit International Ltd. The data is treated sensitively, we protect it from misuse and never provide it to a third party.

Thank you for your assistance, we are wishing you a successful treatment.

Basic patient data

Basic partner data:

Please fill in your full name and surname according to your passport or your personal identity document.

Last Name

First name

Title

DOB

Maiden name

Permanent address (street and no.)

Town

Postcode

Country of residence

Telephone no. incl. country code

Your contact e-mail

Partner's last name

Partner's first name

Partner's title

DOB of partner

Partner Adresss

Town

Postcode

Country where your partner lives

Telephone no. incl. country code

Email partner

Treatment history

How long have you been trying to conceive?

The cause of infertility

Please enter the cause

Have you undergone any IVF treatments using your own eggs?

Yes
NO

Year:	Used stimulation protocol	FSH dosage	Follicle growth at OPU	Was ICSI used?	How many embryos were transferred?	How many embryos were vitrified??	Conclusion

Add another record

Have you undergone any IVFtreatments using donor eggs?

Yes
NO

Year:	How many embryos originated?	How many embryos were transferred?	How many embryos were vitrified?	Conclusion

Add another record

Are you familiar with your current partner's semen analysis?

Yes
NO

Year:	Ejaculate volume in mll	Concentration v mil/ml	Motility in % %	Progressive motility in %b %	Normal morphology in % %

Add another record

Information about the patient:

Height (cm)

Weight (kg)

Your blood type

Do you have children with your current partner?

Yes

number of sons

Are they healthy? YesNO

Which diseases do they suffer from?

number of daughters

Are they healthy? YesNO

Which diseases do they suffer from?

How many times have you given birth?

How many time have you been pregnant?

Have you ever miscarried?

Yes
NO

in which week approximately?

Is your menstrual cycle regular?

Yes
NO

indicate the date of last menstrual period

Are you using any medications to regulate your menstrual cycle?
Especially hormonal contraceptives

Yes
NO

enter the drug name?

Are there any hereditary disorders or fertility issues in your family?
Hematological or neurological diseases (Huntington's chorea), Psoriasis, Diabetes, Cancer, Thyroid failure, Anorexia, Albinism, Down Syndrome, Celiac disease, Galactosemia, Anemia, cleft lip, palate or Syndactyly, Hemophilia, Daltonism (colourblindness)

Yes
NO

write which diseases

When is the last time you have had a transvaginal ultrasound?

Date of ultrasound

Was any myoma/fibroid found?

Yes
NO

Was any ovarian cyst found?

Yes
NO

What was your uterine lining thickness(endometrium)? (enter in mm)

Results of blood tests, taken within first three days of your menstrual cycle

Date of test:

Hormone levels:

FSH LH TSH Prolactin

AMH ng/ml pmol/l

Have you undergone Hysterosalpingogram? (radiologic procedure to investigate the shape of uterine cavity and the shape and patency of the fallopian tubes)

Yes
NO

What was the result?

Have you undergone diagnostic or operative laparoscopy?

Yes
NO

What was the result?

Surgeries:
Especially those of the reproductive organs (ovaries, fallopian tubes, uterus) and appendix.

Yes
NO

Which surgery exactly and in which year?

Do you suffer from any disease that may worsen during pregnancy?
Diabetes, high blood pressure, cardiomyopathy, neuropathy

Yes
NO

specify?

Have you ever been treated for a sexually transmitted disease?
Hepatitis B and C, syphilis, HIV…

Yes
NO

specify?

Are you allergic to anything?

Yes
NO

write what you are allergic to?

Are you currently taking any medications on a regular basis?

Yes
NO

write which drugs?

Do you smoke?

Yes (more than 10 cigarettes a day)
Yes (less than 10 cigarettes a day)
NO

How did you find out about us?

please, write where from

If you would like to share other information that could be pertient to your treatment, please, list it here

Would you like to use donor eggs? After clicking YES, you will have the opportunity to select your donor's requirements

Yes

To select the most suitable female donor for you, please fill in your characteristics:

The natural color of your hair?

The color of your eyes?

Your partner's natural hair color?

Your partner's eye color?

The questionnaire helps choose the egg donor who would correspond the most with your physical state. Neither of following facts may be guaranteed or claimed. All the data are used only for selection of the most suitable donor. Egg donation is voluntary, gratuitous and anonymous under the law, therefore no other information may be given to you

Donor's height

Donor's weight

What shall be the minimum education of Your donor

Which hair color?

Which eye color?

Which leisure time activities do you prefer at Your donor?

Short notes regarding donor selection

Would you like to use donated sperm? By clicking YES you will have the option to select your requirements for the donor

Yes

To select the most suitable male donor for you, please fill in your characteristics:

The natural color of your hair?

The color of your eyes?

Your partner's natural hair color?

Your partner's eye color?

The questionnaire helps choose the sperm donor who would correspond the most with <strong>your physical state</strong>. Neither of following facts may be guaranteed or claimed. All the data are used only for selection of the most suitable donor. Egg donation is voluntary, gratuitous and anonymous under the law, therefore no other information may be given to you

Donor's height