{"id":5428,"date":"2021-10-14T11:00:13","date_gmt":"2021-10-14T11:00:13","guid":{"rendered":"https:\/\/next-fertilitynordic.com\/new\/?page_id=5428"},"modified":"2021-10-14T11:13:30","modified_gmt":"2021-10-14T11:13:30","slug":"medical-history-form-ivf","status":"publish","type":"page","link":"https:\/\/next-fertilitynordic.com\/en\/medical-history-form-ivf\/","title":{"rendered":"Medical History Form (IVF)"},"content":{"rendered":"<section class=\"wpb-content-wrapper\"><p>[vc_row][vc_column]<div id=\"sc_title_1324122410\"\n\t\tclass=\"sc_title sc_title_default  vc_custom_1634210008283\"><h3 class=\"sc_item_title sc_title_title sc_align_center sc_item_title_style_default\">Medical History Form (IVF)<\/h3><h6 class=\"sc_item_subtitle sc_title_subtitle sc_align_center sc_item_title_style_default\">Thank you for choosing Next Fertility Nordic as your clinic!<\/h6><\/div><!-- \/.sc_title -->[\/vc_column][\/vc_row][vc_row full_width=&#8221;stretch_row&#8221; el_id=&#8221;services&#8221; css=&#8221;.vc_custom_1621326659792{background-image: url(https:\/\/next-fertilitynordic.com\/wp-content\/uploads\/2021\/02\/page_gradient.jpg?id=1199) !important;}&#8221;][vc_column offset=&#8221;vc_col-lg-offset-3 vc_col-lg-6&#8243;]\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f5589-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"5589\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/en\/wp-json\/wp\/v2\/pages\/5428#wpcf7-f5589-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"5589\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.3\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f5589-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/><input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/fieldset>\n<div class=\"columns_wrap\">\n\t<div class=\"column-1_1\">\n\t\t<h2>PERSONAL DATA\n\t\t<\/h2>\n\t\t<h6>First name, surname\n\t\t<\/h6>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"Ees-japerekonnanimi\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"Ees-japerekonnanimi\" \/><\/span>\n\t\t<\/p>\n\t\t<h6>Date of birth or social security number\n\t\t<\/h6>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"isikukood\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"isikukood\" \/><\/span>\n\t\t<\/p>\n\t\t<h6>Address\n\t\t<\/h6>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"aadress\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"aadress\" \/><\/span>\n\t\t<\/p>\n\t\t<h6>Phone number\n\t\t<\/h6>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"telefon\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"telefon\" \/><\/span>\n\t\t<\/p>\n\t\t<h6>E-mail address\n\t\t<\/h6>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"email\" \/><\/span>\n\t\t<\/p>\n\t\t<h6>Marital status\n\t\t<\/h6>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"perekonnaseis\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"perekonnaseis\" \/><\/span>\n\t\t<\/p>\n\t\t<h6>Spouse\u2019s name\n\t\t<\/h6>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"partnerinimi\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"partnerinimi\" \/><\/span>\n\t\t<\/p>\n\t\t<h6>Spouse\u2019s social security number\/date of birth\n\t\t<\/h6>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"isikukood2\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"isikukood2\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"columns_wrap\">\n\t<div class=\"column-1_1\">\n\t\t<h2>GENERAL INFORMATION\n\t\t<\/h2>\n\t\t<h6>Height\n\t\t<\/h6>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"pikkus\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"pikkus\" \/><\/span> cm\n\t\t<\/p>\n\t\t<h6>Weight\n\t\t<\/h6>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"kaal\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"kaal\" \/><\/span> kg\n\t\t<\/p>\n\t\t<h6>Allergies\n\t\t<\/h6>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"allergiad\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"allergiad\" \/><\/span>\n\t\t<\/p>\n\t\t<h6>Current medications\n\t\t<\/h6>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"ravimid\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ravimid\" \/><\/span>\n\t\t<\/p>\n\t\t<h6>Other: vitamins or natural supplements\n\t\t<\/h6>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"vitamiinid\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"vitamiinid\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"columns_wrap\">\n\t<div class=\"column-1_1\">\n\t\t<h2>GYNECOLOGICAL HISTORY\n\t\t<\/h2>\n\t\t<h6>Age at the first menstrual period\n\t\t<\/h6>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"aastaselt\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"aastaselt\" \/><\/span>\n\t\t<\/p>\n\t\t<h6>Menstrual cycle length\n\t\t<\/h6>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"days\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"days\" \/><\/span>\n\t\t<\/p>\n\t\t<h6>Bleeding days\n\t\t<\/h6>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"veritsus\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" min=\"1\" max=\"30\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"veritsus\" \/><\/span>\n\t\t<\/p>\n\t\t<h6>Any menstrual pain?\n\t\t<\/h6>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"valusid\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"valusid\" \/><\/span>\n\t\t<\/p>\n\t\t<h6>First day of your last menstrual period\n\t\t<\/h6>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"date\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"date\" \/><\/span>\n\t\t<\/p>\n\t\t<h6>Pregnancies, births (please indicate years)\n\t\t<\/h6>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"synnitused\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"synnitused\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"columns_wrap\">\n\t<div class=\"column-1_1\">\n\t\t<h2>FERTILITY RELATED HISTORY\n\t\t<\/h2>\n\t\t<h6>Since when have you tried to get pregnant? (year)\n\t\t<\/h6>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"soovrasestuda\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"soovrasestuda\" \/><\/span>\n\t\t<\/p>\n\t\t<h6>Have you had any previous fertility examinations? Which?\n\t\t<\/h6>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"viljatusuuringud\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"viljatusuuringud\" \/><\/span>\n\t\t<\/p>\n\t\t<h6>Previous fertility treatments. When?\n\t\t<\/h6>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"viljatusravi\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"viljatusravi\" \/><\/span>\n\t\t<\/p>\n\t\t<h6><br \/>\nIf you have performed ovulation tests, on which day the test becomes positive?\n\t\t<\/h6>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"ovulatsioonitest\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"ovulatsioonitest\" \/><\/span>\n\t\t<\/p>\n\t\t<h6>Are there any problems in your sexual life?\n\t\t<\/h6>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"suguelu\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"suguelu\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"columns_wrap\">\n\t<div class=\"column-1_1\">\n\t\t<h2>PAST MEDICAL HISTORY\n\t\t<\/h2>\n\t\t<h6><br \/>\nChronic diseases (diabetes, asthma, gastritis, high blood pressure, bowel diseases, repeated respiratory infections, kidney\/liver diseases)\n\t\t<\/h6>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"haigused\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"haigused\" \/><\/span>\n\t\t<\/p>\n\t\t<h6>Infectious diseases (HIV, B-, C-hepatitis)\n\t\t<\/h6>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"nakkushaigused\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"nakkushaigused\" \/><\/span>\n\t\t<\/p>\n\t\t<h6>Genital infections (chlamydia, gonorrhea)\n\t\t<\/h6>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"suguhaigused\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"suguhaigused\" \/><\/span>\n\t\t<\/p>\n\t\t<h6>Have you had any operations? Which ones, what year?\n\t\t<\/h6>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"op2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"op2\" \/><\/span>\n\t\t<\/p>\n\t\t<h6>\n\t\t<\/h6>\n\t\t<h6>\n\t\t<\/h6>\n\t<\/div>\n<\/div>\n<div class=\"columns_wrap\">\n\t<div class=\"column-1_1\">\n\t\t<h2>LIFESTYLE\n\t\t<\/h2>\n\t\t<h6>Exposition to radiations or to chemicals\n\t\t<\/h6>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"kemikaalid\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"kemikaalid\" \/><\/span>\n\t\t<\/p>\n\t\t<h6>Smoking habits: number of cigarettes a day?\n\t\t<\/h6>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"suitsetamine\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"suitsetamine\" \/><\/span>\n\t\t<\/p>\n\t\t<h6>Portions of alcohol (by week or by month)?\n\t\t<\/h6>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"alkohol\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"alkohol\" \/><\/span>\n\t\t<\/p>\n\t\t<h6>Use of drugs\/Which ones?\n\t\t<\/h6>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"narko\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"narko\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"columns_wrap\">\n\t<div class=\"column-1_1\">\n\t\t<h2>COVID-19\n\t\t<\/h2>\n\t\t<h6>Have you had coronavirus disease? When?\n\t\t<\/h6>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"covid\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"covid\" \/><\/span>\n\t\t<\/p>\n\t\t<h6>Have you had a vaccine against coronavirus? When?\n\t\t<\/h6>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"vaktsineerimine\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"vaktsineerimine\" \/><\/span>\n\t\t<\/p>\n\t\t<h6>Which vaccine did you receive?\n\t\t<\/h6>\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"manustatudvaktsiin\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"manustatudvaktsiin\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"columns_wrap\">\n\t<div class=\"column-1_1\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"your-acceptance\"><span class=\"wpcf7-form-control wpcf7-acceptance\"><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"your-acceptance\" value=\"1\" aria-invalid=\"false\" \/><span class=\"wpcf7-list-item-label\"><a href=\"https:\/\/next-fertilitynordic.com\/en\/privacy-policy\/\" target=\"_blank\"\n      >I agree to the privacy terms<\/a\n    ><\/span><\/label><\/span><\/span><\/span><br \/>\n<span class=\"button_wide\"><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Submit\" \/><\/span>\n\t\t<\/p>\n\t<\/div>\n<\/div><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n[\/vc_column][\/vc_row]<\/p>\n<\/section>","protected":false},"excerpt":{"rendered":"<p>[vc_row][vc_column][\/vc_column][\/vc_row][vc_row full_width=&#8221;stretch_row&#8221; el_id=&#8221;services&#8221; css=&#8221;.vc_custom_1621326659792{background-image: url(https:\/\/next-fertilitynordic.com\/wp-content\/uploads\/2021\/02\/page_gradient.jpg?id=1199) !important;}&#8221;][vc_column offset=&#8221;vc_col-lg-offset-3 vc_col-lg-6&#8243;][\/vc_column][\/vc_row]<\/p>\n","protected":false},"author":990015,"featured_media":0,"parent":0,"menu_order":1,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-5428","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.4 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Medical History Form (IVF) - Fill in - Next Fertility Nordic<\/title>\n<meta name=\"description\" content=\"This anonymous survey will only take 1 minute. 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