Shady Grove Fertility. Reproductive Science Center. Questionnaire Diabetes £ £ _Thallasemia £ £ _Previous Infertility Testing. Previous urological exam? …
Shady Grove Fertility
Reproductive Science Center
Questionnaire for Men
General Information
Name ___________________________________________________________
Date ________________
Address __________________________________________________________
__________________________________________________________
Telephone ________________________ Home ______________________ Work
__________________________ Cell
Birth date ____________________ Age __________________
Occupation __________________________________________
Ethnic Background ____________________________________
Height ___________________ Weight ___________________
Highest Education _____________________________________ Wifes Name
_______________________________________
Marriage date ____________________________
Referred by: ________________________________
| | |
|Infertility History |Sexual History |
| |
|
|Have you ever fathered a pregnancy? |Has there been any change in your libido or |
|____ yes ____ no |sexual drive? ___ yes ___ no |
|If yes, when year of birth | |
|__________ |Is there any difficulty in maintaining an |
| |erection? ____ yes ____ no |
|Have you ever been told you are | |
|infertile? ____ yes ____ no |Do you ejaculate into the vagina without |
|If yes, when and by whom? |difficulty? ____ yes ____ no |
|_____________________________ | |
| |Do you have any pain or burning with urination|
|Length of time attempting pregnancy |or ejaculation? ___ yes ___ no |
|____ Years ____ Months | |
| |Have you ever had any discharge from the |
|Length of time not using
contraceptives|penis? ____ yes ____ no |
|___________________ | |
| |Frequency of sexual intercourse per week? |
|Did your mother take DES or other |______ |
|medications while pregnant with you? | |
|_____ yes _____ no ______ dont| |
|know | |
|If yes, list: | |
|_______________________________________| |
|___ | |
|_______________________________________| |
|____________ | |
|_______________________________________| |
|____________ |
|
|_______________________________________| |
|___________ | |
| | |
|Have you ever been treated for: | |
|Dates | |
| | |
|Syphilis | |
|_______ | |
|Gonorrhea | |
|_______ | |
|Chlamydia non-specific urethritis | |
|_______ | |
|Prostatitis infection of the prostate| |
|_______
| |
|Infection of the testicles | |
|_______ | |
|Infection of the seminal vesicles | |
|_______ | |
| | |
|Do you have a history of genital herpes| |
|______yes ______no | |
____________________________________________________________________________
_______
Medical/Surgery History Yes No
Dates/Comments
Mumps _____ _____
______________________________
Measles _____ _____
______________________________
Chicken Pox _____ _____
______________________________
Rubella German Measles _____
_____
______________________________
Rheumatic fever _____ _____
______________________________
Elevated Blood pressure _____ _____
______________________________
Heart murmur _____ _____
______________________________
Heart disease _____ _____
______________________________
Diabetes _____ _____
______________________________
Lung disease _____ _____
______________________________
Liver or gall bladder disease _____ _____
______________________________
Jaundice _____ _____
______________________________
Kidney infections _____ _____
______________________________
Hepatitis _____ _____
______________________________
Kidney stones _____ _____
______________________________
Gout ______ _____
______________________________
Urinary tract abnormalities _____
_____
______________________________
Thyroid disease _____ _____
______________________________
Arthritis _____ _____
______________________________
Auto immune diseases lupus, rheumatoid arthritis, etc _____ _____
______________________________
Other serious or chronic diseases
__________________________________________________________________________
Any surgery list type and year
___________________________________________________________________________
____________________________________________________________________________
__________________________
Do you have any allergies to medications: Yes ______ No
______
If yes, which medications
______________________
______________________
Please list any medications you are now taking or Current:
______________________ Past: ______________________
have taken in the past ______________________
______________________
______________________
______________________
______________________
______________________
Any history of therapeutic x-ray treatment or Current:
______________________ Past: ______________________
anti-cancer drugs? ______________________
______________________
______________________
______________________
Have you ever been involved in psychotherapy or counseling? Yes ______
No ______
If yes, please indicate why, when, with whom, and any other pertinent
information __________________________________________
____________________________________________________________________________
__________________________________
Please fill in a review of any current or recent symptoms:
Yes No Yes No
Yes No
Chronic headaches ____ ____ Increased thirst ____ ____
Fatigue ____ ____
History of head injury ____ ____ Increased sweating ____ ____
Tremors ____ ____
Convulsion history ____ ____ Intolerance to heat ____ ____
Desire for extra salt ____ ____
Visual problems ____ ____ Intolerance to
cold ____ ____
Rapid weight change ____ ____
Dizziness ____ ____ Difficulty sleeping ____ ____ Change
of appetite ____ ____
Please include any other information which you believe may be pertinent to
your infertility problem _____________________________
____________________________________________________________________________
_______________________________________
____________________________________________________________________________
___________________
____________________________________________________________________________
___
Occupation/Leisure History Yes No
Dates/Comments
Have you ever been employed in an occupation with _____ _____
______________________________
sustained high temperature?
Do you drive long distances as part of your employment? _____ _____
______________________________
Do you use hot tubs, saunas, etc? _____ _____
______________________________
Exposed to chemical or x-rays in work or hobby _____ _____
______________________________
Please list Amount per day or
week
Caffeine _____ _____
______________________________
Smoking _____ _____
______________________________
Alcohol _____ _____
______________________________
Marijuana _____ _____
______________________________
Drugs not prescribed, list _____ _____
______________________________
Please describe recreational/sports activities frequency, length of time,
etc ________________________________________
____________________________________________________________________________
___________________________
____________________________________________________________________
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
__________________________________________________________
Medical
problems:
____________________________________________________________________________
_________
Sisters ages __________ medical problems:
________________________________________________________________________
Brothers ages __________ medical problems:
______________________________________________________________________
Is there a family history of: Yes No
Comments
Birth defects or genetic diseases _____ _____
______________________________
Infertility _____ _____
______________________________
Hormone problems _____ _____
______________________________
Miscarriages/stillbirths _____ _____
______________________________
Pregnancy problems _____ _____
______________________________
Cancer _____ _____
______________________________
Stroke _____ _____
______________________________
Heart disease _____ _____
______________________________
Lung disease _____
_____
______________________________
Diabetes _____ _____
______________________________
Thyroid/endocrine problems _____ _____
______________________________
High blood pressure _____ _____
______________________________
Any women who have never menstruated _____ _____
______________________________
Any men who have never had to shave _____ _____
______________________________
Any additional comments you would like to make that you feel may be
pertinent and have not already been addressed:
____________________________________________________________________________
________________________________
____________________________________________________________________________
_____
____________________________________________________________________________
_______
Pre-conceptual Health Screening
Have you ever been tested for: Yes No If yes, give
dates/results
Hepatitis B _____________________________________
HIV AIDS _____________________________________
Rubella
_____________________________________
TB Tuberculosis
_____________________________________
Blood Type _____________________________________
Tay-Sachs _____________________________________
Gaucher Disease _____________________________________
Canavan Disease _____________________________________
Cystic Fibrosis _____________________________________
Sickle cell _____________________________________
Diabetes _____________________________________
Thallasemia _____________________________________
____________________________________________________________________________
______________________
Previous Infertility Testing
|Previous urological exam? | yes | no |
| Results: |
|_________________________________________________________________________|
|__________________ |
|Previous semen analysis? | yes | no |
| Results: Date Count million/cc |
|Motility moving
Morphology normal shape |
|________ ______________ _____________ |
|____________ |
|________ ______________ _____________ |
|____________ |
| |
|________ ______________ _____________ |
|____________ |
| |
|________ ______________ _____________ |
|____________ |
| |
| |
|Specialized sperm testing? | yes | no |
| | | |
|Acrosome reaction, sperm | | |
|penetrating assay, antibody| | |
|testing | | |
| Results which
tests: |
|_________________________________________________________________________|
|______ |
|Specific treatment for Male| yes | no |
|Infertility? | | |
| Details: |
|_________________________________________________________________________|
|__________________ |
| |
E:/clinical/Questionnaire for Mendoc jss
11/14/01
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Source:shadygrovefertility.com
