Have you had surgery of the penis or Yes No Reason testicles? Do you have any allergies, including to Yes No What medication? Examinations you must have before treatment can HIV 1 and HIV 2 Examined on (date) Positive Negative Hepatitis Examined on (date) Positive Negative and anti-HCV) Chlamydia Examined on (date) Positive Negative (If your partner is under 26 years of age) Semen analysis Date made Where Lifestyle Do you smoke (including No Have you stopped within the last year? Yes, what and how many joints) or use snuff? Date: per day? Alcohol, units per week 0 2 2 5 5 10 More than 10 – – – Caffeine (coffee, black None Yes, how many cups/glasses per day tea, cocoa, cola) Fruit, approx. how many Less than 5 5 6 daily More than 6 daily – do you eat per day? Approx. how many of Less than 500 grams 500 grams More than 500 vegetables do you eat per day? How often do you eat fish? What vitamin supplements do you take? Height Weight Solemn Declaration With my signature, I confirm that I have received information both in writing and verbally about the fertility treatment and that the above information is accurate and correct. ________________________________________________________________________ Date and signature
Have you had surgery of the penis or testicles? Yes No Reason Do you have any allergies, including to medication? Yes No What Examinations you must have before treatment can HIV 1 and HIV 2 Examined on (date) Positive Negative Hepatitis and anti-HCV) Examined on (date) Positive Negative Chlamydia (If your partner is under 26 years of age) Examined on (date) Positive Negative Semen analysis Date made Where Lifestyle Do you smoke (including joints) or use snuff? No Have you stopped within the last year? Date: Yes, what and how many per day? Alcohol, units per week 0 – 2 2 – 5 5 – 10 More than 10 Caffeine (coffee, black tea, cocoa, cola) None Yes, how many cups/glasses per day Fruit, approx. how many do you eat per day? Less than 5 5 – 6 daily More than 6 daily Approx. how many of vegetables do you eat per day? Less than 500 grams 500 grams More than 500 How often do you eat fish? What vitamin supplements do you take? Height Weight Solemn Declaration With my signature, I confirm that I have received information both in writing and verbally about the fertility treatment and that the above information is accurate and correct. ________________________________________________________________________ Date and signature
EN-Info-IVF-290713.docx