Online application form

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Data of the Woman:

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Please, fill following data correctly:
(The pink fields are required.
These has to be filled in, to allow you to go to the next step.)
  
 
Title:

  		Following documents can be submitted before oocytes pickup.
(not older than 30 days)
Surname:

  		Firstname:

hepatitis B (HBsAg, Anti-HBc)

hepatitis C (Anti-HCV-Ab)  

Date of birth:
Job:

HIV 1, 2 (Anti-HIV-1,2)

 

Height:
 cm 		Weight:
kg 		Blood group/Rh factor:
 		Rubella-Immunstatus:
Street:
   		ZIP Code/City:
  		General information
(sollten uns, sofern Auffälligkeiten sind, sofort mitgeteilt werden!)
Country:
 		Phone.:
Allergies:
 		Hereditary defects (deseases):
E-Mail:
  		Fax:
Surgery in past:
 		Another risk factors:
Interval of the cycle between the first day of the mensturation and the next beginn of the menstruation (without taking the medicaments):

   
Address/Data about the/attending physician/-gynaecologist
 
Title:
Surname:
Firstname:
Street:
ZIP Code/City:
Country:
 		E-Mail:
Phone.:
Fax:
   
Hormonal analyse:
Please fill in in the case you have now the results of bloodtaking for hormon analyse (what kind of medicaments?)

Date

Day
of cycle

Hormonal therapy

 E2
pg/mL 		Prog
ng/mL 		T-frei
pg/mL 		DHEAS
ng/mL 		LH
mlU/mL 		FSH
mlU/mL 		Prol
ng/mL 		TSH
μU/mL
     
The last two periods (the first day of the last period): Next to the last period:
 		Last period:
 
Present medication (e.g. for the correction the value of Prolaktin, for substitution of thyroid gland and other):
 
Present medication for the follicular stimulation(What kind of the stimulation"Down - Regulation“?, What kind of medication? Which medicaments for stimulation have you taken?, Which dose have you taken?, How many ampules?...), corresponding reaction on the medications (how many ampules and doses have you needed, etc.), the count of taken oocytes (eggs), the count of the fertilised embryos and the quality, the count of frozen embryos, symptoms of overstimulation (no, middle, intense):
(Please for short description):