Questionnaire

Before you book your Initial Consultation or treatment using our Shared Care Scheme at AVA-Peter, please fill in the questionnaire below. This will help us to assess your medical history and ask you for any additional information we need. It also allows us more time at the Initial Consultation to discuss the procedure, to answer further questions and to give you all the explanations you need.

If you have any queries, we are ready to answer them in English on 007 81 2336 3059 between 07:00-14:00 Central European Time (06.00-13.00 UK time). You can also reach us by e-mail at info@clinic.avapeter.com

Information about the embryo donation recipient (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

E-mail

How would you prefer to be contacted?

Medical information

Height (cm)

Weight (kg)

Eye colour

Hair colour

Blood group

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?

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

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

E-mail

How would you prefer to be contacted?

Medical information

Height (cm)

Weight (kg)

Eye colour

Hair colour

Blood group

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
-hat 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

Both partners

What are your reasons for seeking treatment with donated embryos?

How did you find out about AVA-Peter?

Please indicate if you are interested in coming for an Initial Consultation
Yes
No

Please indicate if your are interested in our Shared Care Scheme (instead of coming for an Initial Consultation)
Yes
No

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

Security code

Please type in the numbers below. This security measure enables us to protect your private information

Our patients tell their stories (40 unique stories...)

14.02.2010 How we became parents.

12.11.2009 Thank you, AVA-Peter.

Questionnaire

Information about the embryo donation recipient (female partner)

General information

Medical information

Information about the male partner

General information

Medical information

Both partners

Physiology of human reproduction Identifying the cause infertility Infertility treatment Preimplantation genetic diagnosis (PGD) Egg donation Sperm donation Embryo donation Embryo donation procedure Initial Consultation Schedule Shared Care Schedule Treatment with donor embryos Questionnaire Prenatal diagnostic methods Terminology Frequently asked questions Acknowledgments Press about us Our patients tell their stories (40 unique stories...) 14.02.2010 How we became parents. ...Ava Peter in St. Petersburg had a very good reputation and very high pregnancy rate so we decided to use them also because it is easy to get cheep flights from our country.... 12.11.2009 Thank you, AVA-Peter. My husband and I had tried to have children for few years when we found out that the only way for me to conceive was through egg donation. In 2005 We contacted a private fertility clinic in Finland and during the next 2 years went through several egg dona Site map	Deutsch Nederlands Dansk Svenska Norsk Русский About the clinic News Specialists Start treatment For Colleagues Trip to St.Petersburg Prices Contacts Home » Embryo donation » Questionnaire Questionnaire Before you book your Initial Consultation or treatment using our Shared Care Scheme at AVA-Peter, please fill in the questionnaire below. This will help us to assess your medical history and ask you for any additional information we need. It also allows us more time at the Initial Consultation to discuss the procedure, to answer further questions and to give you all the explanations you need. If you have any queries, we are ready to answer them in English on 007 81 2336 3059 between 07:00-14:00 Central European Time (06.00-13.00 UK time). You can also reach us by e-mail at info@clinic.avapeter.com Information about the embryo donation recipient (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 E-mail How would you prefer to be contacted? Medical information Height (cm) Weight (kg) Eye colour Hair colour Blood group 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? 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 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 E-mail How would you prefer to be contacted? Medical information Height (cm) Weight (kg) Eye colour Hair colour Blood group 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 -hat 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 Both partners What are your reasons for seeking treatment with donated embryos? How did you find out about AVA-Peter? Please indicate if you are interested in coming for an Initial Consultation Yes No Please indicate if your are interested in our Shared Care Scheme (instead of coming for an Initial Consultation) Yes No If you have any questions that are not answered by information on the AVA-Peter website, please give details below Security code Please type in the numbers below. This security measure enables us to protect your private information

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