EUROPE IVF International  
  • Take advantage of our special offer of a combination of methods in section Special offer

Entry Questionnaire

Prior to commencing the treatment, we would like to kindly ask you to fill in the contact form below carefully. This will help us assess your health and design an individual programme of treatment for you prior to our initial meeting. We will then have more time in the meeting for discussing the treatment and addressing your questions. After submitting the questionnaire, you will be contacted shortly by one of our doctors or coordinators.

Basic information





In case of egg or embryo donation IVF (IVF DO, IVF DE):



Family history

Does any member of your family (parents, siblings) have/has had any serious illness?

Does any member of your family suffer from cerebral vascular accidents, trombosis of the lower extremities, pulmonary (lung) embolism, blood disease or any other blood coagulation (clotting) disorder?

Does any member of your family have/has had a child with inborn error of development, Down Syndrome or other syndromes?

Personal history

Are you currently being treated for any condition? Are you taking or have you ever taken any medications over a period longer than 1 month?

Have you ever had any surgery? If so, when and what type of surgery (particularly if any reproductive system or abdominal surgery was involved)?

Have you ever had any serious injuries?

Gynecological history

How long is your menstrual cycle i.e. how often do your periods occur (e.g. 26-28 days, the fist day of your period is calculated as the first day of your menstrual cycle)? How long does your period last?

Prior pregnancies/deliveries? Date? Natural vaginal birth or cesarian section? Your child’s /children’s health condition?

Have you ever suffered a pregnancy loss? If yes, when? Was it induced abortion, natural miscarriage or missed miscarriage?

Last Pap smear (please, indicate year and results).

First day of your last period (please, indicate date mm/dd).

Medication use history

Do you take any medications on a regular basis? Which ones?

Allergy history

Are you allergic to any medications? Which ones?

Current condition

How long have you and your present partner been trying to conceive?

Last FSH, LH, AMH test date and results.

Last Serology for sexually transmitted diseases?














Last TSH test date and result

Have you had a breast exam? (date of the test, type of examination - mammography, ultrasound and result)

Please, indicate the number of prior inseminations, IVF or ICSI attempts (if already treated for a fertility problem) and any possible complications you have had (hyperstimulation syndrome OHSS, surgeries…).

Course of last ovarian stimulation - a) year, b) medications used, c) first dose, d) number of follicles, e) number of eggs, f) number of embryos to be transferred, g) number of embryos frozen.

Date of your last GYN exam? Results and date of your last ultrasound exam?

Male partner data




In case of donor sperm IVF (IVF DS):

Are you being treated for any serious condition now?

Have you ever been treated for any serious condition before?

Do you take any medicines? Which ones?

Have you ever had any surgery? If so, when and what type of surgery?

Are you allergic to any medications? Which ones?

Last Serology for sexually transmitted diseases?














Last semen analysis results (if performed). Sperm count per 1 ml.

Mobility in %

Morphology (percentage of sperm that have a normal shape)

Information concerning both partners

Would you like to have a face-to-face initial consultation and examination at our clinic?

Would you like to have your initial consultation online, via Skype?

Would you like to have your initial consultation via phone?

Would you like us to prepare a plan of your treatment without initial consultation, based on the results and information provided by you?

Would you like us to arrange accommodation for you in Prague?

Your questions