Personal information »couples wishing to conceive«

In order to prepare for your visit, we would appreciate it if you could provide some answers to the following questions.

The form will be treated confidentially and only used for the purposes of your treatment.
None of the data provided will be transferred to third parties!

Our questions for her

All questions marked with * are required fields.

Period / monthly cycle*

Have you already undergone fertility treatment?*

Have you conceived as a couple in the past?*

Have you conceived with another partner in the past?*
Which one of you?*

Do you have any allergies?*

Do you take medication?*

Do you suffer from a serious illness?*

Does your partner suffer from a serious illness?*

Have you had an operation in the past?*

Has the patency of the fallopian tubes been tested?*

Has a sperm analysis been completed?*

Have either you or your partner undergone a sterilisation procedure?*

Has your partner had or do you have any fertility-limiting complications (e.g. undescended testis, testicular tumour)?*

Do you have sufficient vaccine protection (twice) against measles and rubella?*

Do you smoke?*

Does your partner smoke?*

May we inform your doctor of your treatment reports in writing?*

General information

Are you married to one another?*

How did you hear about us?

Data protection notice

We would like to alert you to the fact that all data transmitted to us is stored and processed with the help of electronic data processing. The data entered in this form will be deleted after submission. We handle the information you provide with strict confidentiality and do not transfer it to any other party. Please consult our data protection notice.

Mask requirement

I have been informed of the requirement to wear an N95 (FFP2) mask at all times during the visit.

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