Domestic partnership
How long have you been seeking pregnancy:
COUPLE’S INFORMATION
:::: SHE ::::
Age
Weight
Hight cm.
Region of Residence—Seleziona un'opzione—AbruzzoBasilicataCalabriaCampaniaEmilia-RomagnaFriuli-Venezia GiuliaLazioLiguriaLombardiaMarcheMolisePiemontePugliaSardegnaSiciliaToscanaTrentino-Alto AdigeUmbriaValle d’AostaVenetoOther

:::: HE ::::
Age
Weight
Hight cm.
Region of Residence—Seleziona un'opzione—AbruzzoBasilicataCalabriaCampaniaEmilia-RomagnaFriuli-Venezia GiuliaLazioLiguriaLombardiaMarcheMolisePiemontePugliaSardegnaSiciliaToscanaTrentino-Alto AdigeUmbriaValle d’AostaVenetoOther

:::: LEI ::::
If you have done a hysterosalpingography, indicate the result—Seleziona un'opzione—OpenClosedDoubtful results
If you performed ultrasound monitoring of spontaneous ovulation (i.e. without ovulation stimulating drugs), indicate the result:—Seleziona un'opzione—RegularIrregularNo ovulation
If you have measured a dosage on the 2nd or 3rd day of the hormone cycle of of the FSH, LH, 17 beta estradiol and prolactin, please indicate the result:
FSH MUI/ML
LH MUI/ML
17 Beta Estradiol PG/ML
Prolactin NG/ML
AMH (anti-Mullerian hormone)
Brief notes on menstrual history
Any further information:

:::: LUI ::::
If you have done one or more spermiograms tests:
Number Million/ML
Motility percentage
Percentage in conformity with norms:
Difficulty to have an intercourseYesNo
Intercourse frequency:—Seleziona un'opzione—1-2 per settimana1-2 per mese
Any further information:
Your e-mail address, please:

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