PERSONAL DATA

First name, surname

Date of birth or social security number

Address

Phone number

E-mail address

Marital status

Spouse’s name

Spouse’s social security number/date of birth

GENERAL INFORMATION

Height

cm

Weight

kg

Allergies

Current medications

Other: vitamins or natural supplements

GYNECOLOGICAL HISTORY

Age at the first menstrual period

Menstrual cycle length

Bleeding days

Any menstrual pain?

First day of your last menstrual period

Pregnancies, births (please indicate years)

FERTILITY RELATED HISTORY

Since when have you tried to get pregnant? (year)

Have you had any previous fertility examinations? Which?

Previous fertility treatments. When?

If you have performed ovulation tests, on which day the test becomes positive?

Are there any problems in your sexual life?

PAST MEDICAL HISTORY

Chronic diseases (diabetes, asthma, gastritis, high blood pressure, bowel diseases, repeated respiratory infections, kidney/liver diseases)

Infectious diseases (HIV, B-, C-hepatitis)

Genital infections (chlamydia, gonorrhea)

Have you had any operations? Which ones, what year?

LIFESTYLE

Exposition to radiations or to chemicals

Smoking habits: number of cigarettes a day?

Portions of alcohol (by week or by month)?

Use of drugs/Which ones?

COVID-19

Have you had coronavirus disease? When?

Have you had a vaccine against coronavirus? When?

Which vaccine did you receive?

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