We guarantee you a baby this spring!

Questionnaire

Du kan træffe Birgitte telefonisk på +45 53 31 00 39 på følgende tidspunkter:

Tirsdag fra kl 15 til 17, torsdag fra kl 17 til 19 og lørdag fra kl 10 til 12.

 

Related pages in other lnguages: English Egg donation Deutsch Eizellspende Netherlands Eiceldonatie

What treatment options are you looking for?

Information about female partner

General information

Full name *


Date of birth


Nationality


Educational level


Occupation


Country of residence


Address


Phone number *

including country code


Home phone

including country code


Please confirm a suitable time and date for us to call you?

Time and Date


E-mail


Skype

Skype account name / login and your city


Medical information

Height (cm)


Weight (kg)


Eye colour


Hair colour


Blood group


Rhesus factor


Please describe in detail any medical conditions you have


Do you take any medication regularly?


Do you have any allergies?


Do you smoke?

If so, how many cigarettes per day?


Have you had surgery in the abdominal area?

If yes, please provide detailed information about diagnosis and operation


Have you had any genital or urinary infections?


How long is your menstrual cycle?


When was the first day of the last menstruation?


Do you take any hormonal medication?


Have you been pregnant in this relationship?

Please describe the outcomes (births/miscarriages/terminations)


Have you been pregnant in previous relationships?

Please describe the outcomes (births/miscarriages/terminations)


Please describe any fertility investigations and treatments you have had

If you have had IVF treatment, please describe
-treatment protocols;
-which medications and which dozages of medications you used;
-for how long you took the medications;
-how many eggs were retrieved;
-whether they were fertilised by simply mixing them with sperm (IVF) or via ICSI;
-how many embryos were made as a result
-what quality the embryos were
-at what stage the embryos were transferred (i.e. after how many days)
-how many embryos were transferred
-what the result of treatment was


Your partner

Please select




Information about the female partner

General information

Full name


Date of birth


Nationality


Educational level


Occupation


Country of residence


Address


Home phone

including country code


Mobile

including country code


Please confirm a suitable time and date for us to call you?

Time and Date


E-mail


Medical information

Height (cm)


Weight (kg)


Eye colour


Hair colour


Blood group


Rhesus factor


Please describe in detail any medical conditions you have


Do you take any medication regularly?


Do you have any allergies?


Do you smoke?

If so, how many cigarettes per day?


Have you had surgery in the abdominal area?

If yes, please provide detailed information about diagnosis and operation


Have you had any genital or urinary infections?


How long is your menstrual cycle?


When was the first day of the last menstruation?


Do you take any hormonal medication?


Have you been pregnant in this relationship?

Please describe the outcomes (births/miscarriages/terminations)


Have you been pregnant in previous relationships?

Please describe the outcomes (births/miscarriages/terminations)


Please describe any fertility investigations and treatments you have had

If you have had IVF treatment, please describe
-treatment protocols;
-which medications and which dozages of medications you used;
-for how long you took the medications;
-how many eggs were retrieved;
-whether they were fertilised by simply mixing them with sperm (IVF) or via ICSI;
-how many embryos were made as a result
-what quality the embryos were
-at what stage the embryos were transferred (i.e. after how many days)
-how many embryos were transferred
-what the result of treatment was


Own comment


Information about the male partner

General information

Full name


Date of birth


Nationality


Educational level


Occupation


Country of residence


Address


Home phone

including country code


Mobile

including country code


Please confirm a suitable time and date for us to call you?

Time and Date


E-mail


Medical information

Height (cm)


Weight (kg)


Eye colour


Hair colour


Blood group


Rhesus factor


Please describe any medical conditions you have


Do you take any medication regularly?


Do you have any allergies?


Do you smoke?

If so, how many cigarettes per day?


Have you had surgery in the abdominal area?

If yes, please provide detailed information about diagnosis and operation


Have you had any genital or urinary infections?


Have there been any pregnancies in your previous relationships?


Please describe the results of any semen analysis you have had


Please describe any fertility investigations an treatments you have had (if different or additional to the information provided by your partner, f.E. IVF in your previous relationship)

If you have had IVF treatment, please describe
-whether the eggs were fertilised by simply mixing them with sperm (IVF) or via ICSI;
-how many eggs retrieved/fertilized
-what quality the embryos were
-at what stage the embryos were transferred (i.e. after how many days)
-how many embryos were transferred
-what the result of treatment was


Your expectations from the treatment at our clinic

What are your reasons for seeking treatment with donated eggs?


Would you like to visit us for the Initial consultation?


What aspects of treatment are the most important for you?

you may choose one, several, all options or none

Your attitude to the process of egg donor selection

Do you want to choose your egg donor yourself from a detailed data base ?



Do you want your AVA-Peter Doctor to match a donor for you?



Do you want to receive as much as possible information about your egg donor?



Do you want to receive only very little information about your egg donor?



Please mark which criteria are important for you when choosing your egg donor

you may choose one, several, all options or none

If you would like to add anything about your egg donor expectations, please write below


Other information

How did you find out about AVA-Peter?

Name of doctor/therapist


Name of the clinic


Which media?


Describe, please


If you have any questions that are not answered by information on the AVA-Peter website, please give details below


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A blog by Tone Bråten family counsellor

A blog — to help you on your journey to become parents!

Our patients tell their stories



  • Willeke and Mario from Netherlands come to AVA-Peter for egg donation treatment… Enjoy this touching and sincere documentary by Jorien van Nes