Questionnaire PARTNER

Questionnaire PARTNER in fertility treatment


Information from partner 

Name:                               


Civil registration number (CPR no.):                          


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? _____________________________            

Name of the woman: ______________________________________ 

Civil registration number (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 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)  

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 next questions concern genital diseases 

1. Have you had mumps after puberty?      Yes □    No □

2. Have you had an epididymitis infection?
(chlamydia, gonorrhoea or other)?     Yes □    No □ 
 
3. Have you currently or have you had undescended testicles (one or both)?      
                 Yes, one □             Yes, both □     No  □    Don't know □ 
     
4. Have you undergone surgery for inguinal hernia?    Yes  □   No □

5. Have you previously been told that you have had varicocele?    Yes □     No  □

If, yes, have you undergone surgery for varicocele?         Yes  □   No  □
Do you still experience discomfort from varicocele?       Yes  □   No □

6. Have you had a vasectomy?   Yes □     No  □

If yes, when (year) ____________       

7. Have you had an operation for refertilisation?   Yes  □   No □

If yes, when (year) ____________        

8. Have you had other surgery on your penis, testicles or epididymides? 
Yes  □   No □ 

If yes, year and place ______________________________________________  

9. Have you been treated for cancer?  Yes  □   No □

If yes, year and place ____________________________________________________ 

10. Have you had radiotherapy on your testicles?   Yes  □   No □     

11. Have you had chemotherapy?      Yes □       No □

12. Have you previously been examined at the Department of Growth and          
Reproduction at Rigshospitalet?       Yes   □     No □

13. Have you had your sperm frozen?    Yes  □          No □

The next questions concern diagnostic evaluation of infertility and sex life 

1. Have you had a semen analysis?   Yes  □      No □

If yes, please bring a copy of the results to the consultation. 
 
If no, it is important that your GP refers you to a basic semen analysis and that you bring a copy of the results to the consultation. 

2. Have you ever made a previous partner pregnant?   Yes □       No □

If yes, when (year) ____________________________________ 

3. How long have you and your current partner been trying for a child?                          _____year(s)_____month(s)  

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 1 week 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 10.00 – 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: _____________________________________________________ 

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