Dotazník

Vážení klienti,

tento dotazník slouží ke zrychlení a upřesnění komunikace mezi vámi a vaší koordinátorkou a lékařem. Vyplňte prosím požadované údaje. Koordinátorka vás následně bude kontaktovat.

Děkujeme za vyplnění
REPROMEDA

  • What are you interested in?

  • Basic patient data

  • Date Format: DD dot MM dot YYYY

  • Basic partner data

  • Date Format: DD dot MM dot YYYY

  • Treatment history

  • Information about the patient

  • Hematological or neurological diseases (Huntington's chorea), Psoriasis, Diabetes, Cancer, Thyroid failure, Anorexia, Albinism, Down Syndrome, Celiac disease, Galactosemia, Anemia, cleft lip, palate or Syndactyly, Hemophilia, Daltonism (colourblindness)

  • Results of blood tests, taken within first three days of your menstrual cycle

    Hormone levels:
  • Diabetes, high blood pressure, cardiomyopathy, neuropathy
  • Hepatitis B and C, syphilis, HIV… 

  • Information about the partner

  • Hematological or neurological diseases (Huntington's chorea), Psoriasis, Diabetes, Cancer, Thyroid failure, Anorexia, Albinism, Down Syndrome, Celiac disease, Galactosemia, Anemia, cleft lip, palate or Syndactyly, Hemophilia, Daltonism (colourblindness)
  • Hepatitis B and C, syphilis, HIV… 

  • How did you learn about Repromeda clinic?

  • This field is for validation purposes and should be left unchanged.