Personal information for single women wishing to conceive

In order to prepare for your visit, we would appreciate it if you could provide some answers to the following questions. Alternatively, you can download a PDF here to print and fill in with your personal information.

Our questions for her

All questions marked with * are required fields. The form will be treated confidentially and only used for the purposes of your treatment.

Period / monthly cycle*

Have you already undergone fertility treatment?*

Former pregnancies?*

Do you have any allergies?*

Do you take medication?*

Do you suffer from a serious illness?*

Have you had an important operation in the past?*

Has the patency of the fallopian tubes been tested?*

Have you undergone a sterilisation procedure?*

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

Do you smoke?*

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

General information

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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.

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