Journal for the man, IVF or IUI treatment, return to Vitanova before the consultation Personal details Name Date of birth Social Security No.: Passport No.: Address Country Telephone Mobile E-mail Private Work Profession Spouse or partner’s name Children's names and years of birth, whether your own or spouse/partner’s Pregnancies and births Pregnancies with another than Number Year your current partner Miscarriages with another than Number Year your current partner General information about your health Have you had surgery? (tick box) Yes No Diagnosis Have you had any serious illnesses? Yes No What Do you have any chronic illness (e.g. Yes No What diabetes, metabolic diseases)? Are there any hereditary diseases in the Yes No What family, including mental? Are you taking any medication, including Yes No What (preparation) psychoactive medicine? Have you previously had medication Yes No What (preparation) treatment, including psychoactive medicine? Have you had inflammation of the Yes No testicles? Have either or both testicles not dropped? Yes No
Journal for the man, IVF or IUI treatment, return to Vitanova before the consultation Personal details Name Date of birth Social Security No.: Passport No.: Address Country Telephone Mobile E-mail Private Work Profession Spouse or partner’s name Children's names and years of birth, whether your own or spouse/partner’s Pregnancies and births Pregnancies with another than your current partner Number Year Miscarriages with another than your current partner Number Year General information about your health Have you had surgery? (tick box) Yes No Diagnosis Have you had any serious illnesses? Yes No What Do you have any chronic illness (e.g. diabetes, metabolic diseases)? Yes No What Are there any hereditary diseases in the family, including mental? Yes No What Are you taking any medication, including psychoactive medicine? Yes No What (preparation) Have you previously had medication treatment, including psychoactive medicine? Yes No What (preparation) Have you had inflammation of the testicles? Yes No Have either or both testicles not dropped? Yes No
EN-Info-IVF-290713.docx