Questionnaire
Please answer the questions below so that we can get to know you better. They will help us get the necessary information about you before proceeding with the required tests, medical history, documents, etc.
Name:
*
Name
Surname
Date of birth (you must be 18 - 32 years old):
*
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Mobile phone number:
*
In case you want us to call you on a specific day and time please note:
E-mail:
*
Address:
*
Profession:
Nationality:
*
Skin colour:
*
Hair colour:
*
Eye colour:
*
Height:
*
Weight:
*
Are you familiar with the process of donating eggs? Have you ever been a donor?
*
Yes
No
Do you have children?
*
Yes
No
Do you have a regular period?
*
Yes
No
Are you taking any medicine/s?
*
Yes
No
If you are taking any medicine(s), please note:
Do you have some kind of anemia?
*
Yes
No
I don't know
Do you have any health problem?
*
Yes
No
If any, please mention:
Have you had any surgeries and if so, which ones?
Who introduced you to us?
*
I have been fully informed about the privacy policy of Medimall Clinic (www.medimall.gr) and I consent to the management of the information I have voluntarily filled in.
Submit
Should be Empty: