Report Generator | Life Experts Centre

Life Experts Questionnaire Form

Basic Information

Personal

Last Name:

First Name:

Date of Birth:

{femaleLastName}

{femaleFirstName}

Phone Number:

Email:

Nationality:

Address:

Country:

{femaleFirstName}

Partner

Last Name:

First Name:

Date of Birth:

{femaleLastName}

{femaleFirstName}

Phone Number:

Email:

Nationality:

{femaleFirstName}

Identification

Citizenship:

Health Insurance:

BSN:

{femaleLastName}

National Identity Number:

{femaleLastName}

Passport Number:

{femaleLastName}

Initial Clinical Question

Number of months trying to be pregnant:

Have you ever been pregnant:

Miscarriage:

Pregnancy Termination:

Ectopic Pregnancies:

Births:

Children still alive:

Partner have children from previous relationships:

{femaleLastName}

Family History

Are there any cases of breast cancer in the family:

Is there any genetic disease in the family:

Is diabetes known in the family:

Are there any psychiatric illnesses in the family:

Is there any history of thrombosis in the family:

Is there any heart disease in the family:

Is there any high blood pressure in the family:

Are there any cases of early menopause known in the family:

Has there been repeated miscarriage in the family:

Is there any thyroid disease in the family:

Are there any fertility problems in the family:

{femaleLastName}

Clinical Research

Weight (kg):

Height (cm):

Change in weight during the last year:

Do you smoke:

{femaleLastName}

If yes, how much per day:

Do you drink alcoholic drinks:

Do you use drugs:

Do you come in contact with harmful substances at work:

If yes, which one?

{femaleLastName}

Medical History

Have you ever had a surgery:

If yes, which surgeries:

Have you ever been treated for any disease:

Have you had any other medical issues in the past:

{femaleLastName}

Have you ever been hospitalized:

Have you ever been treated for genital inflammation:

If yes, when:

Have you ever had cervical smear test:

If yes, when?

{femaleLastName}

Have you received vaccination for HPV:

{femaleLastName}

Which medication are you taking regularly:

{femaleLastName}

Which substance are you allergic to:

{femaleLastName}

Previous Fertility Treatment

Have you ever had any infertility treatment:

If yes, how many attempts:

Which treatment?

{femaleLastName}

Other treatment:

{femaleLastName}

Ovulation induction:

{femaleLastName}

Details:

Ovulation induction through injections:

Details:

IUI:

Details:

{femaleLastName}

Did you have IVF/ICSI before:

Where did you do the IVF/ICSI:

{femaleLastName}

Did you do multiple IVF/ICSI:

How many Attempts:

{femaleLastName}

Attempts

# of Oocytes

# of Embryo

1

{femaleLastName}

2

{femaleLastName}

3

{femaleLastName}

4

{femaleLastName}

5

{femaleLastName}

Have you ever had problems with transfers or egg retrivals:

{femaleLastName}

Have you done egg donation before:

Donor type:

{femaleLastName}

# of Transfers

{femaleLastName}

Cycle Information

Have you ever used any form of contraception:

If yes, which one:

Did you ever have any problems with your IUD:

When did you have your menstrual period for the 1st time:

{femaleLastName}

Is your cycle regular:

How long is your menstrual cycle:

{femaleLastName}

Do you have a lot of symptoms before your period starts:

If yes, describe?

{femaleLastName}

Do you have pronounced pain during your period:

{femaleLastName}

Do you suffer from intermenstrual bleeding:

{femaleLastName}

Do you suffer blood loss after sexual contact:

Do you have pain during sexual contact:

How often do you have sexual contact per month:

When did your last period start:

Own remarks:

{femaleLastName}

Partner Family and Clinical Information

Family

Are there any cases of breast cancer in the family:

Is there any genetic disease in the family:

Is diabetes known in the family:

Are there any psychiatric illnesses in the family:

Is there any history of thrombosis in the family:

Is there any heart disease in the family:

Is there any high blood pressure in the family:

Are there any cases of early menopause known in the family:

Has there been repeated miscarriage in the family:

Is there any thyroid disease in the family:

Are there any fertility problems in the family:

{femaleLastName}

Clinical Research

Weight (kg):

Height (cm):

Change in weight during the last year:

Do you smoke:

If yes, how much per day:

Do you drink alcoholic drinks:

Do you use drugs:

Do you come in contact with harmful substances at work:

If yes, which one?

{femaleLastName}

Partner Medical History

Have you ever had a surgey

If yes, which interventions have you underfone:

Have you ever been treated of any of the following diseases:

{femaleLastName}

Have you ever had mumps:

{femaleLastName}

Have you ever had severe pain in one or both testicles:

Have you ever been treated for an undescended testicles:

Have you ever been treated for a bladder infection (cystitis):

Do you have problems with erection or ejaculation:

Have you had any other medical issues in the past:

Have you ever been hospitalized:

Which medication are you taking regularly:

{femaleLastName}

Which substance are you allergic to:

{femaleLastName}

Has a semen analysis already been performed:

{femaleLastName}

If yes, what is the result:

{femaleLastName}

If you have had other partner, were any of them ever pregnant by you:

{femaleLastName}