Information from the woman 

Name:                               
Civil registration number (CPR no.):                     
Address: 
Job title/occupation: _______________________________________________      
                
Telephone/mobile phone (private):                
Telephone (work): 

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? ________________________________________________________________ 

Will you be receiving treatment as:                                                                      
A single person   □
A couple     □   
Spouse/partner's name: ________________________ CPR. no. ___________________ 

For couples seeking treatment:

Do you and your current partner have a child together?        □  Yes    □  No 
 
Note: If yes, please call us on +45 35 45 40 71, weekdays 08.30-12.00 a.m.

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?   □ Yes    □ No 
  (except for the Nordic countries and the Netherlands)                
• 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 (e.g. thrombosis or other serious condition) and surgery (except for gynaecological diseases, see later section) 
What diseases and when (year)?

• ____________________________________________________
• _____________________________________________________
• _____________________________________________________
• _____________________________________________________ 

 
4.    Are you being treated for the following? 

o  High blood pressure:            □ Yes   □ No 
 
o  Cardiovascular disease:      □ Yes   □ No Specify:_____________________________ 
 
o   Lung disease:                       □ Yes   □ No Specify:______________________________
 
o   Kidney disease:                  □ Yes    □ No Specify:______________________________
 
o   Metabolic disorder:            □ Yes   □ No Specify:_____________________________ 
 
o   Diabetes:                             □ Yes    □ No Specify:______________________________ 
 
o   Other:                                   □ Yes    □ No Specify:_____________________________  

5.    Do you take medicine on a daily basis or often?                

□ Yes    □ No 
If yes,   
please state what medicine(s) and what dose(s) (it is a good idea to bring a list):  

• _________________________________________________
• ________________________________________________ 

6.    Do you take dietary supplements on a daily basis, such as fish oil?      

□ Yes  □ No
(Fish oil can cause bleeding during surgical procedures such as egg retrieval). 

If yes,   please specify 

• _________________________________________________
• _________________________________________________ 

7.    How do you assess your physical health in general? 

□ Very good         □ Good       □  Fairly good       □ Poor       □ Very poor 

Describe, if necessary: _________________________________________________________ 
____________________________________________________________________________ 

8. Do you have chronic pain?                   

□ Yes      □ No 
If yes,  

• insert a cross on the line below (VAS- score) 

 0_____________________________________________________________10      
No pain                                                                    Worst possible pain   

The next questions concern your menstruation and sex life 

1. Is your menstruation regular, i.e. can you predict it within +/- 3 days?        

□ Yes     □ No 

2.    How long is your cycle?                                                                              

____ days (from day 1 in a menstrual period to day 1 in the  next menstrual period):                              

3.    Have you previously been on the birth-control pill?           

□ Yes    □ No 

If yes,     
for how many years:                                                                ________________    
When did you stop taking birth-control pills?                    ________________ 

4.    How long have you wanted/been trying for a child?                     

_______ year(s) _______months 

The following questions concern any previous gynaecological diseases and pregnancies      

1.    Have you had pelvic inflammatory disease with fever and abdominal pain

□ Yes    □ No 

2.    Have you had a chlamydia infection without symptoms?          

□ Yes     □ No 

3.    Have you previously been treated for cervical cell changes?            

□ Yes    □ No 
If yes,      

• have you had a conic section (cervical conisation)? 
• When _______________________________________ 

4.    When did you last have a cervical screening?      

• Year? _________________________________________ 
• Was it normal?                      □ Yes      □ No 

If no, please explain   ________________________________________ 

5.    Have you been treated for any other gynaecological disease(s)?       

(e.g. endometriosis, polyps, fibromas)   □ Yes     □  No 

If yes,  

• what? ____________________________________________
• year and place ________________________________________ 

6.    Have you had surgery: 

• on your fallopian tubes?                    □ Yes     □  No

If yes,  

• year and place_______________________________________________
• why? ____________________________________________________  
• were your fallopian tubes removed?  □ Yes, the right tube    □ Yes, the left tube   □ No 

 
    •     on your ovaries?               □  Yes     □ No 
If yes,  

• oyear and place________________________________
• why? __________________________________ 
• was one of your ovaries removed?              □  Yes     □ No 

7.    Have you ever been pregnant?                                        

□ Yes     □ No

If yes,   

• have you given birth?                                       □ Yes      □ No
• year______________________________________________ 

8.    Have you ever been pregnant outside the uterus (ectopic pregnancy)?     

Yes □      No □

If yes,   

• year and place of treatment ____________________
• was your fallopian tube removed?    
  □ Yes, the right tube        □ Yes, the left tube       □ No 

9.    Have you ever had a miscarriage?                    

□ Yes      □ No 

If yes,     

• in what week of pregnancy? ___________________________
  year and place _____________________________________ 
   
• in what week of pregnancy? ___________________________
  year and place _____________________________________

10.    Have you ever had an induced abortion?             

□  Yes     □ No 

If yes,           

• year_____________________________________________ 

The following questions concern diagnostic evaluation and treatment for infertility 

1.    To examine whether there is a clear passage through your fallopian tubes, have you had 

• a hysterosalpingoultrasonography (HSU)?         

□   Yes    □  No 

If yes,  

• year, result ________________________________ 

• a hysterosalpingogram (HSG)?                                

□ Yes     □ No 

If yes,  

• year, result ________________________________ 

•  a laparoscopy?                     

□ Yes    □  No 

If yes,  

•  year, hospital, result ________________________________ 

 
Note: If you have answered yes to one or more of these three procedures, please bring a copy of the description of the procedure(s) to your consultation. 

2.    Have you tried:  
 

• IVF/ICSI?                         

□  Yes     □ No 

If yes,  

• year and place________________________________ 
• how many times? IVF or ICSI? _____________ 

• Insemination - sperm from partner (if relevant)?           

□ Yes      □ No 

If yes,  

• year and place________________________________
• how many times? _____________________________ 

• Insemination - donor sperm?                

□ Yes      □ No 

If yes,   

• year and place _______________________________
• how many times? _____________________________ 

• Treatment with donor eggs?                

□ Yes      □ No 

If yes,   

• year and place _______________________________
• how many times? _____________________________ 

 
Note: If you have answered yes to one or more of these treatments, please bring a copy of previous treatments to your consultation. 

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?

(e.g. recurrent miscarriages or loss of a child)                               
□ Yes      □  No                         

3.    Have you been exposed to:  

• Sexual abuse or other 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 or other psychotropic drugs?   
□ Yes   □ No 
9. Have you been treated with antidepressants?  
    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?                                                                                     ____________ 

2.    Have you smoked regularly in the past?                              
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 tried to become pregnant?                                                               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:  __________________________________ 

Concerns? 

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 and sent to the department by secure mail on our home page. 
 
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:________________________________________________________