Upitnik za pacijente za IVF

Datum rođenja / Date of Birth

Adresa boravka / Permanent Address

Broj mobilnog telefona / Mobile Phone

E-mail adresa / E-mail address

Potvrdi e-mail adresu / Confirm your e-mail address

Visina (cm) / Hight (cm)

Telesna masa (kg) / Body mass (kg)

Da li patite od nekih alergija? / Do you have any allergies?

Da li uzimate neke lekove redovno? / Do you take any medications regularly?

Da li pušite? / Do you smoke?

Da li ste imali neku operaciju u abdominalnoj regiji?
Ukoliko jeste, molim vas napišite detaljne informacije o dijagnozi i operaciji /
Have you had any surgery in the abdominal area?
If yes, please provide detailed information about diagnosis and operation

Da li ste imali neke genitalne ili urinarne infekcije? Molim vas opišite /
Have you had any genital or urinary infections? Please describe

Sa koliko godina ste imali prvi menstrualni ciklus? / At what age your period started?

Sa koliko godina ste imali prvi seksualni odnos? / At what age does sexual intercourse start?

Molim vas napišite precizne datume vaših menstrualnih ciklusa. Na primer: početak 10.09., i kraj 15.09. /
Please write your precise menstrual cycle dates. For example: start on 10.09., finish on 15.09.

Koji vremenski period prođe izmedju vaših menstrualnih ciklusa. Na primer: 28 dana /
What is your interval between periods? For example: 28 days

Da li ste ikada bili trudni? Molim vas opišite razvoj događaja po godinama (rodjenja/pobačaji/abortusi) /
Have you ever been pregnant? Please describe the outcomes and years (births/miscarriages/terminations)

Koliko dugo pokušavate da ostanete trudni? / How long you have been trying to get pregnant?

Molim vas napišite nam podatke o vašim ranijim IVF pokušajima / Please tell us about your previous IVF treatment attempts.

1. Koliko puta ste pokušali IVF? / How many times you performed IVF?

2. Sa kojim protokolima (dugački ili kratki)? / Treatment protocols (long or short)?

3. Koje lekove i u kojim dozama ste koristili za hormonsku stimulaciju? / Which medications and which dosages of medications you used?

4. Koliko dugo ste uzimali lekove? / For how long you took the medications?

5. Koliko jajnih ćelija su vam izvadili? / How many eggs were retrieved?

6. Jel su bila oplođena putem IVF ili ICSI metode? / Whether they were fertilized by IVF or via ICSI?

7. Koliko embriona ste dobili? / How many embryos were made as a result?

8. Koji kvalitet embriona ste dobili? / What quality the embryos were?

9. U kom stadijumu su embrioni trasferisani i koliko komada? / At what stage the embryos were trasnferred and how many embryos were trasnferred?

10. Šta je bio rezultat lečenja? / What was the result of treatment?

Molim vas detaljno opišite bilo koje zdravstveno stanje koje imate / Please describe in details any medical conditions you have

Molim vas navedite uzroke neplodnosti ako su vam poznati / Please indicate your infertility causes (if known)

Godine majke / Advanced maternal age
Muški faktor / Male factor
Nepravilnosti rada imunog sistema / Immune system disorders
Oštećenje jajovoda / Damage to fallopian tubes
Problemi sa hormonima / Hormonal causes
Endometrioza / Endometriosis
Posledice ranijih operacija / Consequences of previous surgeries
Urinarne infekcije ili infekcije reproduktivnih organa / Infections within urinary and reproductive organs
Anatomske abnormalnosti / Anatomical abnormalities
Neodgovarajuća težina / Improper body mass
Bolesti metabolizma / Metabolic diseases

Da li imate u vašoj porodici neke nasledne poremećaje ili probleme sa fertilitetom? / Are there any hereditary disorders or fertility issues in your family?

Hematološke ili neurološke bolesti / Hematological or neurological diseases (Huntington`s chorea)
Psorijaza / Psoriasis
Dijabetes / Diabetes
Rak / Cancer
Problemi sa štitastom žlezdom / Thyroid failure
Ankoreksija / Anorexia
Albinizam / Albinism
Daunov sindrom / Down syndrome
Celijaklija / Celiac disease
Galaktosemija / Galactosemia
Anemija / Anemia
Zečija usna / Cleft lip
Hemofilija / Hemophilia

Ukoliko želite, možete ovde podeliti sa nama još neke informacije koje mogu biti od važnosti za vaše lečenje /
If you would like to share other information that could be pertinent to your treatment, please list it here

INFORMACIJE O PARTNERU / PARTNER INFORMATION.

Ime / Name
Prezime / Last Name

Datum rođenja / Date of Birth

Adresa boravka / Permanent Address

Broj mobilnog telefona / Mobile Phone

Molim vas detaljno opišite bilo koje zdravstveno stanje koje imate / Please describe in details any medical conditions you have

Da li imate biološke dece? / Do you have biological children?

Molim vas napišite za koje ste IVF programe zainteresovani? / Please tell us about which IVF programs you are interested in?

VTO sa ICSI / IVF with ICSI
VTO sa PGS / IVF with PGS
Tandem VTO program sa sopstvenim i doniranim jajnim ćelijama / Tandem IVF with own and donor egg cells
VTO sa TESE/microTESE / IVF with TESE/microTESE
VTO sa transferom citoplazme / IVF with cytoplasmic trasfer
VTO sa blagom stimulacijom / IVF with mild stimulation

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Više informacija - Politika privatnosti. / More info - Privacy policy.

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HVALA! / THANK YOU!