NIFTY pro survey IMPORTANT: If on the day of sample collection the data provided in the survey changes, be sure to contact us to update the data. 1. Name and surname*: (name) (name) 2. PESEL*: 3. Date of birth*: 4. Telephone number*: 5. E-mail*: 6. ID card number or, in the absence of ID card - passport number (this number is necessary for insurance. Failure to provide it results in resignation from insurance):?? 7. Weight and height*: (weight) kg, (growth) cm, 8. Fetal age in weeks and days according to USG (on the day of taking the sample for testing)*:?? 9. Number of pregnancies (including the current one)*: 10. Expected delivery date*: 11. Do you want the gender of the child in the result?*: YesNo 12. Single / multiple pregnancy*: singletwin3 and more fetuses13. Do you take any medications?*: YesNo Date of last dose: 14. Have you performed a karyotype test?*:?? NoYes, the result is correctYes, the result is incorrect15. Did the child's father perform a karyotype test?*: NoYes, the result is correctYes, the result is incorrect16. Previous transplant*: TakNie Transplant date: 17. Incorrect reproductive history (repeated 2 or more times)*:?? YesNo18. Historical tumor*: YesYes, therapy is still ongoing.No Term of therapy completion: Questions regarding the last 12 months (in case of a situation older than 12 months, please tick NO)19. Previous stem cell therapy*: YesYes, therapy is still ongoing.No Term of therapy completion: 20. Previous allogeneic blood transfusion*: YesYes, therapy is still ongoing.No Term of therapy completion: 21. Previous cellular immunotherapy*: YesYes, therapy is still ongoing.No Term of therapy completion: 22. Previous heparin therapy*: (also taking medications with a heparin derivative, i.e. Neoparin, Clexane, Fraxiparine, Fragmin, Heparinum, Fraxiparin, Endoksyparin, Innohep, Oksapar, Tinzaparin, Lovenox, Enoxaparin). YesYes, therapy is still ongoing.No Term of therapy completion: 23. Previous albumin therapy*: YesYes, therapy is still ongoing.No Term of therapy completion: 24. Past immunotherapy*: YesYes, therapy is still ongoing.No Term of therapy completion: Questions about the current pregnancy25. In vitro fertilization *: YesNo26. Result ultrasonography (USG) indicates fetal abnormalities *:??">? YesNo 27. Vanishing twin syndrome (twin pregnancy suspected)*: YesNo Date: 28. One fetus has developmental defects (in twin pregnancy)*: YesNo Comments: * CONSENT TO THE PROCESSING OF PERSONAL DATAI consent to the processing of my personal data in compliance with the provisions of Regulation (EU) 2016/679 of the European Parliament and of the Council of 27/04/2016 on the protection of individuals with regard to the processing of personal data and on the free movement of such data and the repeal of Directive 95/46 / WE (Dz. Urz. UE L 2016, No. 119) in connection with the implementation of the order to register and publish the results of molecular tests. Providing data is voluntary, but necessary to process the order.The data includes: name and surname, correspondence address, telephone number, PESEL number, e-mail address, date of birth, health information, identity card or passport number. The data concerns the patient and his legal guardians, if necessary.I have been informed that I have the right to access my data and the possibility of correcting it. The administrator of personal data is TESTDNA sp. Z oo Sp.k., NIP: 634-282-27-48.*mandatory fields IMPORTANT: If on the day of sample collection the data provided in the survey changes, be sure to contact us to update the data.
Zadzwoń teraz, tel. 533 090 626