First Name

Last Name

Birthday

Your cellphone nr/ (landline phone)

Your Home Telephone (landline phones)

Do you have any medical allergies? (penicillin, sulfa, ect.)

Your Position (job)

Your Current and previous education

Do you work with dangerous chemicals?
YesNo

Your ethnical background (which country are you from?)

Marital status (line under)
MarriedWidowCohabitantsSingle

Who in your family has had Testical Cancer, cystic fibrosis or congenital malformation Please Write what they had:

Have you previously had any surgery done in the abdomen or stomach
When (Date)
What was the Surgery for

Has you as a child had surgery in the testes / inguinal hernia? YesNo

Have you had inflammation of the testis / epididymis? YesNo

Name of medication you receive daily

Your Height

Your Weight

How many cigarettes do you smoke daily

How much coffe do you drink during the day?

How many units (alcohol) do you drink a week?

How many hours daily, do you sit with the laptop on your lap?

Do you take anabolic steroids to get bigger muscles? YesNo

How many times have you made a woman pregnant?

How many children do you have?

How many children do you have with your current partner ?

Write a few words about, why you are here today:

For how long have you tried to get pregnant?

Have you tried artificial insemination / treatment earlier?

Have you earlier done spermtest ?