Couple Treatment – Kinderwunsch Centrum München Terminvereinbarung

Step 1 of 4 - Female data

Female Patient

Surname(Required)

Name(Required)

Date of Birth(Required)

Place of Birth(Required)

Street(Required)

Street Number(Required)

City(Required)

Postal Code(Required)

Country(Required)

Email(Required)

Phone number (private)

Phone number (business)

Mobile phone number

Type of Insurance(Required)

Legal

Private

Name of health Insurance(Required)

Insurance Subsidy

Yes

Employment/Profession(Required)

Partner/in

Surname(Required)

Name(Required)

Date of Birth(Required)

Gender(Required)

Männlich

Weiblich

Place of Birth(Required)

Street(Required)

Street Number(Required)

City(Required)

Postal Code(Required)

Country(Required)

Email(Required)

Phone number (private)

Phone number (business)

Mobile phone number

Type of Insurance(Required)

Public

Private

Name of health Insurance(Required)

Insurance Subsidy

Yes

Employment/Profession(Required)

Medical Data Part 1

Are you married to each other?(Required)

Yes

Do you already have children together?(Required)

Yes

Number of children(Required)

Please enter a number greater than or equal to 0.

Female

Height(Required)

Please enter a number from 10 to 999.

Height measured date(Required)

Weight(Required)

Please enter a number from 10 to 999.

Weight measured date(Required)

Male

Height(Required)

Please enter a number from 10 to 999.

Height measured date(Required)

Weight(Required)

Please enter a number from 10 to 999.

Weight measured date(Required)

How long have you been trying to get pregnant? ( this means: cycles with unprotected sexual intercourse)

In months(Required)

Please enter a number from 1 to 99.

Reason for appointment(Required)

Others appointment(Required)

Last period(Required)

How long is your cycle in days? ( Time from the first day of your bleeding to the beginning of your next bleeding )(Required)

Please enter a number from 1 to 99.

Mensuration Cycle(Required)

If hormone values have already been taken, please tell us the values determined

AMH-value

Date acquired

FSH-value

Date acquired

Have you already had preliminary diagnostic tests or treatments in another fertility center?(Required)

Yes

Name of the clinic(Required)

Is there an up-to-date spermiogram? (Not older than 12 months)(Required)

Yes

Date(Required)

Female Patient

Partner/in

Medical Data Part 1

Female

Male

Referring/treating OBGYN:

Referring/treating urologist:

Interpreter