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.

What are you interested in?
Your e-mail

Basic patient data

Basic partner data:

Treatment history

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



Year: How many embryos originated? How many embryos were transferred? How many embryos were vitrified? Conclusion
Add another record



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:

Do you have children with your current partner?











Especially hormonal contraceptives



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)


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








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

Hormone levels:












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




Diabetes, high blood pressure, cardiomyopathy, neuropathy




Hepatitis B and C, syphilis, HIV…
















Partner information:





Hematological or neurological disorders (Huntington's chorea), Psoriasis, Diabetes, Cancer, Thyroid failure, Anorexia, Albinism, Down Syndrome, Celiac disease, Galactosemia, Anemia, Cleft lip, palate or Syndactyly, Hemophilia, Daltonism (colorblindness)


















Hepatitis B and C, syphilis, HIV…












How did you learn about Reprofit clinic?






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

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

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

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




FVV-eng

+420 543 516 001

E-mail:

info@reprofit.cz

WWW:

www.reprofit.cz