Male Patient Form - Glendale AZ

REPRODUCTIVE HEALTH CENTER
MALE PATIENT HISTORY
I. Identifying Information

       
II. TRAVEL/WORK AND GENERAL BACKGROUND

1.
2.
3.
N/AExcessive HeatToxic FumesChemicalsNuclear RadiationOther
II. Medical History
YesNo
YesNo
YesNo
YesNo
Semen AnalysisChlamydia TestMycoplasma TestAntibody TestHamster Egg TestChromosome TestTesticular BiopsyX-ray or Ultrasound of TestesHormonal Tests (FSH,LH,prolactin,testosterone)Thyroid TestsOther- SpecifyNone








YesNo
YesNoN/A
YesNo
YesNo
YesNo
NoneAnemiaAnorexiaAppendicitisArthritisAsthmaBladder InfectionsBlood TransfusionsBreast Milky DischargeBreast SorenessBreast TendernessChest PainChlamydiaChronic BronchitisChronic HeadachesColitisColor BlindDiabetesDizzinessEpilepsyGallbladder ProblemsGonorrheaHeart DiseaseHepatitis Type?HerpesHirsutism (Excess Hair Growth)Rheumatic FeverHigh Blood PressureImmunization:German MeasleKidney InfectionLiver ProblemsLoss of BalanceLupusMeasles:GermanMeasles:RegularNeurological ProblemsNongonococcal UrethritisParasitic InfectionPelvic InfectionPneumoniaPoor Sense of SmellProblems with Skin PigmentationScarlet FeverSeizuresSpastic ColonSyphilisTuberculosisUlcersVisual DisturbancesVitiligoCancer?Thyroid Problems?

   

YesNo
YesNo
YesNo
YesNo
N/AAlcoholCigarettes


IV. SEXUAL HISTORY
YesNo
YesNo
YesNoN/A
YesNo
YesNo
N/APremature ejaculationsRetrograde ejaculations?
YesNo
YesNo
YesNo
YesNo
V. FAMILY HISTORY
YesNoN/A

YesNoN/A

VI. HISTORY OF FERTILITY THERAPY
YesNoN/A
clomiphene citrate (Sereophene, Clomid)hMG (Pergonal)tamoxifentestolactone (Metrodin)bromocriptine (Parlodel)testosterone or Male HormonehCG (Profasi, A.P.L.)fluoxymesterone (Halotestin)GnRH or LHRH (Factrel)urofollitropin or FSHNoneOther
YesNoN/A
YesNoN/A
YesNoN/A
YesNo
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