Diabetes. Thyroid/endocrine problems. Other hormonal problems. High blood pressure Diabetes. Anemia or Thallsemia. Previous Infertility Testing …
HUSBAND QUESTIONNAIRE
General Information Date:
Last Name: First Name:
Address:
Home Phone Number: Work Phone: Cell Phone:
Birth Date:
What is your Ethnic Background?
Height: Weight: Blood Type: Highest Education:
|Name of Gynecologist |Name of Primary Care Physician |
|Name: | |
|Address: | |
|Phone: | |
|Fax: | |
Please send information regarding my care to:
Name
Referred by: Physician Name:
Address:
Phone:
Fax:
Sexual History
| |No |Yes|Explain |
|Has there been any change in your | | | |
|sexual drive | | | |
|Do have any difficulty in maintaining| | | |
|an erection
| | | |
|Do you ejaculate into the vagina with| | | |
|difficulty | | | |
|Do you have burning or pain with | | | |
|ejaculation or urination | | | |
|Do you ever notice any discharge from| | | |
|your penis | | | |
|Frequency of sexual intercourse per | | | |
|week | | | |
|Have your genitals ever been exposed | | | |
|to excessive heat? | | | |
|Have you had any serious injuries to | | | |
|your genitals | | | |
|Is there any history of birth defects| | | |
|in
your family? | | | |
|Is there any history of recurring | | | |
|miscarriages in your family? | | | |
|Have you ever been treated |Date |Comments |
|for: | | |
|Syphilis | | |
|Gonorrhea | | |
|Chlamydia | | |
|Prostatitis | | |
|Infection of the testicles | | |
|Infection of the seminal | | |
|vesicles | | |
|Genital Herpes | | |
|Medical History |Yes |No |Date
|Comments |
|Mumps | | | | |
|Measles Regular | | | | |
|Measles German | | | | |
|Chicken Pox | | | | |
|Rheumatic fever | | | | |
|Scarlet fever | | | | |
|Tuberculosis | | | | |
|Elevated Blood Pressure | | | | |
|Heart murmur | | | | |
|Heart disease | | | | |
|Diabetes | | | | |
|Lung Disease | | | | |
|Ulcers | | | | |
|Appendicitis
| | | | |
|Colitis | | | | |
|Anemia | | | | |
|Poor sense of smell | | | | |
|Loss of balance | | | | |
|Chronic headaches | | | | |
|Blood Transfusion | | | | |
|Parasitic Infection | | | | |
|Nongonoccal Urethritis | | | | |
|Liver or gall bladder disease | | | | |
|Jaundice | | | | |
|Kidney infections | | | | |
|Hepatitis A, B, C | | | | |
|Kidney stones | | | |
|
|Gout | | | | |
|Urinary tract abnormalities | | | | |
|Thyroid disease | | | | |
|Neurological Problems | | | | |
|Arthritis | | | | |
|Auto immune diseases: lupus, | | | | |
|rheumatoid arthritis, etc | | | | |
Other significant conditions:
Do you have any allergies to medications: No Yes
Have you taken prescription medications - Example: antidepressants, Ulcer
medications, Blood pressure Medications, etc?
If yes, please indicate:
|Medication |Diagnosis |Comments |
| | | |
| | | |
| | | |
Any history of radiation treatment of anti-cancer drugs? No Yes
Explain:
Have you ever been involved in psychotherapy or counseling?
No Yes
Explain:
Review of Systems
Yes No Yes No
Yes No
Chronic headaches Increased thirst
Excessive Fatigue
Head Injury Increased sweating Tremors
Seizures Intolerance to heat Desire of
extra salt
Eyesight Problems Intolerance to cold Balding
Dizziness Difficulty swallowing Change in
voice
Acne Change of appetite Change size
of clitoris
Difficulty sleeping Discharge from nipples
Have you loss or gained greater than 10 lbs of weight in the last year? No
Yes
Comments:
Do you follow a particular food diet or have any special dietary habits?
No Yes
Comments:
Have you ever had an eating disorder anorexia or bulimia? No Yes
Comments:
Please include any other information which you believe may be pertinent to
your infertility problems:
Occupation/Leisure History: Yes No Date
Comments
Have you been exposed to chemical or x-rays in work or hobby?
At work, are you exposed to high temperatures?
Do you drive
long distances?
Do you frequently use saunas or hot tubs?
Do you or have you ever used? check all that apply:
Alcohol - How many glasses per week do you usually drink? Wine Beer
Cocktails
Cigarettes - Number of packs / day Number of years smoking Year
Stopped Smoking
Recreational Drugs Marijuana , Cocaine, etc
Specify:
Nutritional Supplements, herbs , etc
Specify:
Family History
Fathers age if alive If no longer living, cause of death
Medical problems:
Mothers age if alive If no longer living, cause of death Age at
menopause
Medical problems:
Sisters ages Medical problems:
Brothers ages Medical problems:
Did you mother have any difficulty with conception or pregnancy? No Yes
|Does anyone in your |Yes |No |Relationship/Comments |
|family have: | | | |
|Birth defects or genetic| | | |
|diseases | | | |
|Infertility | | |
|
|Hormone problems | | | |
|Polycystic Ovaries | | | |
|Miscarriage/stillbirths | | | |
|Pregnancy problems | | | |
|Cancer | | | |
|Stroke | | | |
|Heart Disease | | | |
|Lung Disease | | | |
|Diabetes | | | |
|Thyroid/endocrine | | | |
|problems | | | |
|Other hormonal problems | | | |
|High blood pressure | | | |
|Any women who have never| | |
|
|menstruated | | | |
|Any men who have never | | | |
|had to shave | | | |
Did your mother take any medications ex Diethylstibestrol while pregnant
with you? No Yes Dont Know
If Yes, please specify?
Infertility History
Have you ever fathered a pregnancy? No Yes
Number conceived with current partner?
Number conceived with previous partner?
|Date |Delivered |Aborted |Miscarried |Difficulty |
| | | | |Conceiving |
| | | | | |
| | | | | |
| | | | | |
FERTILITY HISTORY
Pre-conceptual Health Screening
Have you ever been tested for Yes No Date If yes, give
results
Hepatitis A
Hepatitis B
Hepatitis C
HIV
AIDS
Rubella
TB Tuberculosis
Blood Type
Tay-Sachs
Gaucher Disease
Canavan Disease
Cystic Fibrosis
Sickle cell
Diabetes
Anemia or Thallsemia
Previous Infertility Testing
How many years have you had unprotected intercourse? Additional Info:
How many years have you been trying to get pregnant? Additional Info:
Which physician have you seen for evaluation or treatment of infertility?
Name:
Address:
Phone: Fax:
What causes for infertility was found?
Previous Urological exam? No Yes
Comments:
Have you ever had a semen analysis testing? No Yes
|Date |Lab |Count |Motility |Morphology |Comments |
| | | | | | |
| | | | | | |
| | | | | | |
Have you been evaluated for varicocele? No Yes
|Date |Physician |Findings |
| | | |
| |
| |
Have you had a Doppler study? sonogram or ultrasound on the testicle No
Yes
Have you had a varicocele repair? No Yes If Yes, explain
Specialized sperm testing? No Yes Results:
Acrosome reaction? No Yes Results:
Sperm penetrating assay? No Yes Results:
Antibody testing? No Yes Results:
Source:jmu.edu
