Information from partner
Name:
Address:
Danish Personal Id Number (CPR no.):
Job title/occupation:
Telephone/mobile phone (private):
Telephone (work):
Name of your partner: ______________________________________
Danish Personal Id Number (CPR no.) of your partner: ______________________________________
Do you speak Danish?
Yes □ No □
If no, what language(s) do you speak? _____________________________
Is there anything the department should be particularly aware of when we give you information (e.g. hearing or sight impairment)?
Yes □ No □
If yes, what? _____________________________
Is there anything the department should be particularly aware of
In your treatment (religious/cultural aspects)?
Yes □ No
If yes, what? _____________________________
For couples seeking treatment: Do you and your current partner have more than one child together?
Yes □ No □
Note: If yes, please call us on +45 35 45 40 71, weekdays 10 am-12 noon.
We are asking the following questions to exclude the risk that you may have an MRSA bacterial infection
Have you within the last 6 months:
- been admitted to a hospital outside Denmark?
(except for the Nordic countries and the Netherlands) Yes □ No □ - been in contact with anyone with MRSA or have you been infected with MRSA yourself? Yes □ No □
- been or are you being treated for MRSA? Yes □ No □
We will now ask you a couple of questions about your general health. The first questions concern your physical health
1. Are you hypersensitive (allergic) to penicillin or other medicine?
Yes □ No □
If yes,
- what medicine? _______________________________________
- how does your reaction show? ___________________________________
2. Are there any hereditary diseases in your family? Yes □ No □
If yes,
- what diseases? ______________________________________
- _____________________________________________________
3. Previous diseases and operations (other than genital organs)
a. What diseases/operations and when (year)?
- __________________________________________________
- ____________________________________________________
- _____________________________________________________
4. Are you being treated for the following?
- High blood pressure: Yes □ No □
- Cardiovascular disease: Yes □ No □
Specify:_____________________________
- Lung disease: Yes □ No □
Specify:______________________________
- Kidney disease: Yes □ No □
Specify:______________________________
- Metabolic disorder: Yes □ No □
Specify:_____________________________
- Diabetes: Yes □ No □
Specify:______________________________
- Other: Yes □ No □
Specify:______________________________
5. Do you take medicine on a daily basis?
Yes □ No □
If yes, please state what medicine(s) and what dose(s):
- _______________________________________________
- _________________________________________________
Note (perhaps bring a list of medicines)
6. Are you using or have you previously been using performance-enhancing drugs (e.g. anabolic steroids)
Yes □ No □
If yes,
Please state what drugs and when:
- ________________________________________________
- ________________________________________________
7. How do you assess your physical health in general?
□ Very good □ Good □ Fairly good □ Poor □ Very poor
Describe, if necessary:____________________________________________________
______________________________________________________________________
The following questions concern your mental health
1. Have you had or do you have any mental problems/illnesses? Yes □ No □
If yes, please tick the following boxes:
□ Depression
□ Anxiety
□ Stress
□ Post-traumatic stress disorder (PTSD)
□ Schizophrenia
□ Bipolar disorder (manic depression)
□ Anorexia or other eating disorders
□ Other ________________________
2. Have you experienced any traumatic pregnancies/births?
Yes □ No □
(e.g. recurrent miscarriages or loss of a child)
3. Have you been exposed to:
- Sexual abuse or other types of abuse? Yes □ No □
- neglect or childhood trauma? Yes □ No □
Therapy and treatment
4. Are you in contact with a psychologist? Yes □ No □
5. Have you previously been in contact with a psychologist? Yes □ No □
6. Are you in contact with a psychiatrist? Yes □ No □
7. Have you previously been in contact with a psychiatrist? Yes □ No □
8. Are you being treated with antidepressants? Yes □ No □
or other psychotropic drugs? Yes □ No □
9. Have you been treated with antidepressants Yes □ No □
or other psychotropic drugs? Yes □ No □
Elaborate, if necessary ________________________________________________________
The following questions concern lifestyle factors
Your height: ____________ cm
Your weight: ____________ kg
Smoking
1. Do you smoke?
Yes □ No □
If yes, do you smoke every day? Yes □ No □
If yes, how many cigarettes a day? Number: ___________
If not every day, how often? Number: ___________
2. Have you smoked regularly in the past?
Yes □ No □
If yes, how many cigarettes did you smoke a day? Number: __________
When did you stop? Year:_____________
Alcohol
1. How many units of alcohol do you currently drink during a week?
Number: ______
2. About how many units of alcohol did you drink during a week before you decided to try for a baby?
Number: ______
Other intoxicants
1. Do you currently smoke cannabis or use other intoxicants?
Yes □ No □
If yes, what? _____________________________________________
How often? _________________________________________
2. Have you previously smoked cannabis or used other intoxicants? Yes □ No □
If yes, what? _____________________________________________
When did you stop? ___________________________
Exercise
1. Regular physical activity (now):
Running: ________ km/week
Competitive sport at elite level: ________ hours/week
Working out in a gym: ________ hours/week
Cycling, including to work: ________ km/week
Other: __________________________________
2. Regular physical activity (past year):
Running: ________ km/week
Competitive sport at elite level: ________ hours/week
Working out in a gym: ________ hours/week
Cycling, including to work: ________ km/week
Other: __________________________________
3. Are there any circumstances in your life that concern you?
Yes □ No □
For example, your housing situation, finances, work, your network, your own health or a family member's health.
If yes, please describe below:
_________________________________________________________________________________
________________________________________________________________________________
Date:________________ Signature:_____________________________________
Thank you for completing this questionnaire.
Please return your questionnaire no later than 2 weeks before the interview so the doctor can be prepared for the interview.
Upload to www.minsundhedsplatform.dk or sent to the department by secure mail on our home page.
If you have any questions regarding the questionnaire, you are welcome to contact us by telephone 3545 4071, dial 2 on weekdays 08.30 – 12.00 am.
We hope this questionnaire will help our counselling and guidance in connection with your fertility treatment.
Kind regards
Staff
The Fertility Department
Rigshospitalet
The questionnaire was reviewed with (to be completed at the consultation):
Physician:
____________________________________________________________________________
Date: __________________________
Signature of physician: _____________________________________________________