Questionnaire - Patient - Sellmer klinik ApS

In Denmark, women can receive fertility treatment until the age of 46. Sellmer Clinic is not allowed to and cannot help if the patient has reached the age of 46.

According to the legislation on artificial insemination, Sellmer Clinic is obliged to ask several questions regarding the patient’s health and lifestyle. It is crucial that the questions are answered correctly and adequately.

As this is sensitive personal information, it is treated confidentially, stored securely and not disclosed without the patient’s consent.

Please note that by completing and returning this questionnaire, you accept the terms and conditions that apply to treatment at Sellmer Clinic, even if the consent form has not yet been signed. This is particularly relevant in relation to cancellation fees. The fees can be found on Sellmer Clinic’s website.

"*" indicates required fields

Full name*

Date of birth or CPR no. if the patient is resident in Denmark*

Street name and number*

Postal code and city*

Country*

Telephone number incl. country code*

E-mailadress*

Skype name

Education/jobs/business*

Upload ID (Passport or driver's licence)*

Max. file size: 100 MB.

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Patient – Physique

Height*

Weight*

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Patient – Lifestyle

Do you exercise?*

Yes

If YES, which sport

Do you drink alcohol*

Yes

If YES, alcohol consumption per week

Do you smoke (also applies to joints, vapes and snuff products)?*

Yes

If YES, how many per day

If NO, but have stopped within the last year, enter date

Hidden

Patient – Personal data

Have you previously completed a pregnancy?*

Yes

If YES, how many children

If YES, age of child/children

Have you previously received fertility treatment?*

Yes

If YES, when and where?

If YES, with what results (please send medical records)

Upload medical records

Drop files here or

Max. file size: 100 MB.

Have you been examined by your own gynecologist?*

Yes

Upload blood tests

Drop files here or

Max. file size: 100 MB.

Upload ultrasound

Drop files here or

Max. file size: 100 MB.

HSU - upload copy of the answer

Drop files here or

Max. file size: 100 MB.

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Patient – Medical history

Is your cycle regular?*

Yes

Cycle length in days (from day 1 of bleeding to next day 1 of bleeding):

How many days does the bleeding last:

Do you use contraception?*

Yes

If YES, which one:

Have you had a miscarriage during pregnancy*

Yes

If YES, which one

Have you had an induced abortion during pregnancy*

Yes

If YES, which week of pregnancy:

Have you had an ectopic pregnancy?*

Yes

Have you been pregnant with twins?*

Yes

Have you been hormonally stimulated in the past?*

Yes

Do you have other relevant information to upload?*

Yes

Upload

Drop files here or

Max. file size: 100 MB.

Hidden

Patient – Medical history

Do you have or have you had any allergies (e.g., asthma, hay fever, hypersensitivity to medication, etc.)?*

Yes

If YES, which

Haemophilia or coagulation disorders?*

Yes

Metabolic disorders?*

Yes

Infectious diseases?*

Yes

Cancer diseases?*

Yes

Immune disorders?*

Yes

Do you have or have you ever had any sexually transmitted diseases (e.g., chlamydia, gonorrhea or syphilis)?*

Yes

If YES, which

Hepatitis?*

Yes

Epilepsy/fever seizures after puberty?*

Yes

High blood pressure?*

Yes

Diabetes?*

Yes

Kidney or liver problems?*

Yes

Have you previously had surgery?*

Yes

If YES, what type of surgery

If YES, when and where

Other serious illnesses?*

Yes

If YES, which one:

Other uncommon diseases?*

Yes

If YES, which one:

Are you currently being screened for any diseases?*

Yes

If YES, which one:

Hidden

Patient – Medication

Do you use painkillers, including common ones like ibuprofen?*

Yes

If YES, which one:

Are you taking any medication incl. psychotropic drugs?*

Yes

If YES, which one:

Have you previously been in medical treatment, including treatment with psychotropic drugs?*

Yes

If YES, which one:

Hidden

Patient – Risk factors

Have you traveled outside Europe in the last 3 months?*

Yes

If YES, which country

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Partner

Do you have a partner?*

Yes

Gender of partner: Male, Female, Other

Full name

Date of birth or CPR no. if partner is resident in Denmark

Street name and number

Postal code and city

Country

E-mailadress

Telephone number incl. country code

Upload ID (Passport or driver's licence)

Max. file size: 100 MB.

Hidden

Partner – Physique

Height

Weight

Hidden

Partner – Lifestyle

Do you exercise?

Yes

If YES, which sport

Do you drink alcohol?

Yes

Alcohol consumption per week

Do you smoke (also applies to joints, vapes and snuff products)?

Yes

If YES, how many per day

If NO, but have stopped within the last year, enter date

Should your partner donate for the treatment?

Yes

Hidden

Partner – Personal data

Are you related to your recipient (the patient)?

Yes

If YES, how:

Hidden

Partner – Medical history

Do you have or have you had any allergies (e.g., asthma, hay fever, hypersensitivity to medication, etc.)?

Yes

If YES, which

Haemophilia or coagulation disorders?

Yes

Metabolic disorders?

Yes

Infectious diseases?

Yes

Cancer diseases?

Yes

Immune disorders?

Yes

Do you have or have you ever had any sexually transmitted diseases (e.g., chlamydia, gonorrhea or syphilis)?

Yes

If YES, which

Hepatitis?

Yes

Epilepsy/fever seizures after puberty?

Yes

High blood pressure?

Yes

Diabetes?

Yes

Cardiovascular disease?

Yes

Kidney or liver problems?

Yes

Have you previously had surgery?

Yes

If YES, what type of surgery

If YES, when and where

Other serious illnesses?

Yes

If YES, which one:

Other uncommon diseases?

Yes

If YES, which one:

Are you currently being screened for any diseases?

Yes

If YES, which one:

Have you previously had a semen analysis done?

Yes

If YES, which

Other

Hidden

Partner – Medication

Do you use painkillers, including common ones like ibuprofen?

Yes

If YES, which one

Are you taking any medication incl. psychotropic drugs?

Yes

If YES, which one

Have you previously been in medical treatment, including treatment with psychotropic drugs?

Yes

If YES, which one

Hidden

Cause of infertility

Do you know the cause of the infertility (reduced sperm quality, PCO, or other)?*

Yes

If YES, please elaborate

Hidden

Wishes for treatment*

IUI (Insemination)

IVF or ICSI

Egg donation

Want the clinic's assessment

Hidden

In which month do you want the treatment to start

Hidden

I need a sperm donor for the treatment

Yes

Donor categories (ID-release or No ID-release)

Eye color

Hair color

Minimum weight

Maximum weight

Minimum height

Maximum height

Possibly donor name and name of sperm bank

I need an egg donor for the treatment

Yes

Donor categories (ID-release or No ID-release)

Eye color

Hair color

Minimum height

Maximum height

Ethnicity

Hidden

I want to be treated in*

Aarhus (Jutland)

Copenhagen

Privatlivspolitik*

I hereby confirm to have read Sellmer Clinics privacy policy*

recaptcha

Patient – Physique

Patient – Lifestyle

Patient – Personal data

Patient – Medical history

Patient – Medical history

Patient – Medication

Patient – Risk factors

Partner

Partner – Physique

Partner – Lifestyle

Partner – Personal data

Partner – Medical history

Partner – Medication

Cause of infertility

Why choose Sellmer Clinic for your treatment?

High success rate

Easy transport

Transparent prices

No waiting time

Anette Sellmer

Do you need advice?