Clearing Schedule

The woman

Given name: *
Family name: *
Address: *
Place:
Postal code: *
City: *
Country: *
Identification number/date of birth: *
Email: *
Phone number: *
Partners sex: *

The partner

Given name: *
Family name: *
Address: *
Place:
Postal code: *
City: *
Country: *
Identification number/date of birth: *

The woman

What kind of treatment are you interested in: *

Cause of infertility, if you know it:
Previous examinations:
Have you been tested for open fallopian tubes?: *
Number of previous pregnancies, and with whom:
Number of previos births: *
- Year of birth:
- Year of birth:
- Year of birth:
- Year of birth:

Have you had some of the following blood tests taken?

- AMH: *
- FSH: *
- FSH value: (xx,x)
- LH: *
- LH value: (xx,x)

Have you taken any of the following tests?

HIV 1+2, no more than twenty-four months old: *
Hepatitis B, no more than twenty-four months old: *
Hepatitis C, no more than twenty-four months old: *
Syphilis, no more than twenty-four months old: *
Cell sample from the cervix, no more than two years old: *
- When?: Pick date (dd-mm-yyyy)
Have you had German measles (Rubella)?: *
Are you vaccinated with MMR vaccine (measles-mumps-rubella)?: *
Are your periods regular: *
Average length of menstrual cycle in days:
Do you take medication?: *
- Note the name, strength, dosage and reason?:
Previous surgeries:
Chronic/hereditary diseases:

Previous treatments

Describe the number of treatments, the used medications, the number of eggs retrieved as well as the number transfered, and the number of pregnancies:
Do you have any allergies to medications or anything else?: *
- Describe what and how you react:
Weight in kilograms: *
Height in cm: *
Do you smoke?: *
- Number per day:
Alcohol?: *
- Number of danish standard drinks per week:

33cl, regular (5%vol) beer is approximately one danish standard drink

Name of practitioning physician?:
Pick date (dd-mm-yyyy)
Would you like us to contact you?:
Would you like us to book a free phone consultation for you?:
Would you like to visit us for a free medical consultation?:
What time would you prefer?:

This clinic is part of the VivaNeo group in Denmark, where all employees with revelance to your treatment will have access to your journal.

Furthermore, there is administrative staff who will have access to your journal in order to carry out tasks related to economics, statistics, reports, etc.

Have you read and accept form of consent above?: *

The partner

Cause of infertility, if you know it:
Previous examinations:
Sperm sample (normal/abnormal):
Do you take any kind of medication?: *
- Note name, strength, dosis, and reason:
Previous surgeries:
Chronic/hereditary diseases:
Do you have any allergies to medications or anything else?: *
- Describe what and how you react:
Weight in kilograms:
Height in cm:
Do you smoke?: *
- Number per week:
Alcohol?: *
- Number of standard drinks per week:

33cl, regular (5%vol) beer is approximately one danish standard drink