Our policies regarding Covid-19
en Español
(520) 733-0083
Reproductive Health Center
4518 E. Camp Lowell Drive
Tucson
,
AZ
85712
Phone:
(520) 733-0083
Fax:
(520) 733-0083
100-5000
Url:
https://www.ivftucson.com/
info@ivftucson.com
About Us
A Letter to Our Patients
What Sets Us Apart
Communities We Serve
Meet Our Team
IVF Success Rates
Our Happy Families
Causes of Infertility
What Causes Infertility?
Age and Fertility
Endometriosis
PCOS (Polycystic Ovarian Syndrome)
Fertility Treatment
Fertility Treatment for Specific Populations
Embryo Adoption
Surrogacy
LGBT Couples
Conception After Tubal or Vasectomy
Oocyte Cryopreservation (Egg Freezing)
Developing a Fertility Treatment Plan
Ovulation Induction
Intrauterine Insemination (IUI)
IVF including ICSI and AH
Frozen Embryo Transfer
Preimplantation Genetic Screening (PGS)
Male Fertility Treatment
Donor Gametes (Eggs and Sperm)
Glossary of Fertility Terms
Holistic Fertility Care
Nutrition
Building Healthy Families
Mind-Body Medicine
Acupuncture
Massage
Reproductive Health Education
Frequently Asked Questions
Costs
Sample Ovulation Induction & IUI Cost
Insurance Information
Understanding Infertility
What’s New in Fertility Treatment
Contact
Patient Forms
Female Patient Form
Male Patient Form
Video Gallery
About Us
A Letter to Our Patients
What Sets Us Apart
Communities We Serve
Meet Our Team
IVF Success Rates
Our Happy Families
Causes of Infertility
What Causes Infertility?
Age and Fertility
Endometriosis
PCOS (Polycystic Ovarian Syndrome)
Fertility Treatment
Developing a Fertility Treatment Plan
Ovulation Induction
Intrauterine Insemination (IUI)
IVF- In Vitro Fertilization
Frozen Embryo Transfer
Preimplantation Genetic Screening (PGS)
Male Fertility Treatment
Donor Gametes (Eggs and Sperm)
Glossary of Fertility Terms
Fertility Treatment for Specific Populations
Embryo Adoption
Surrogacy
LGBT Couples
Conception After Tubal or Vasectomy
Oocyte Cryopreservation (Egg Freezing)
Holistic Fertility Care
Nutrition
Building Healthy Families
Mind-Body Medicine
Acupuncture
Massage
Reproductive Health Education
Frequently Asked Questions
Insurance Information
Understanding Infertility
What’s New in Fertility Treatment
How to Switch Fertility Doctors
Contact
New Patient Forms
Female Patient Form
Male Patient Form
Video Gallery
Contact Us
Male Patient Form -
Glendale AZ
Home
»
Reproductive Health Education
»
New Patient Forms
»
Male Patient Form
REPRODUCTIVE HEALTH CENTER
MALE PATIENT HISTORY
I. Identifying Information
Date
First & Last Name
Partner's First & Last Name
Street, City, State
Zip Code
Telephone Number - Home:
Cell:
Work:
Date of Birth(mm/dd/yyyy)
Partner's Date of Birth(mm/dd/yyyy)
Duration of Relationship
Duration of Infertility, if present
Insurance Company
None
Insurance I.D.#
II. TRAVEL/WORK AND GENERAL BACKGROUND
All present employment –
title(s), location, brief description, number of years employed:
1.
2.
3.
Are you or have you ever been exposed to any of the following during employment or military service:
N/A
Excessive Heat
Toxic Fumes
Chemicals
Nuclear Radiation
Other
II. Medical History
Weight
Height
Blood Type(if known)
Have you lost greater than 20 pounds of weight in the last year?
Yes
No
Do you follow a particular food diet or have any special dietary habits?
Yes
No
If yes, specify:
List the forms and frequency of regular vigorous exercise (swimming,cycling,running) and age at which you began them:
Exercise:
Hrs/wk
Age
Exercise:
Hrs/wk
Age
None
Do you frequently take saunas or steam baths?
Yes
No
Have you ever had surgery in the pelvic area?
Yes
No
If yes, specify date and type of surgery:
Which of the following tests have you had performed? Check all that apply and the results:
Semen Analysis
Chlamydia Test
Mycoplasma Test
Antibody Test
Hamster Egg Test
Chromosome Test
Testicular Biopsy
X-ray or Ultrasound of Testes
Hormonal Tests (FSH,LH,prolactin,testosterone)
Thyroid Tests
Other- Specify
None
When?
Results?
When?
Results?
When?
Results?
When?
Results?
When?
Results?
When?
Results?
When?
Results?
When?
Results?
When?
Results?
When?
Results?
When?
Results?
Is your partner currently seeing a doctor for evaluation of infertility?
Yes
No
If yes, specify physician name and location:
Does the doctor feel that your partner has an infertility problem?
Yes
No
N/A
If yes, how is she being treated?
Has she ever had children with another man?
Yes
No
If yes, when?
Do you have any allergies to any medications?
Yes
No
If yes, what reactions do you have? Please list.
Have you ever received X-rays in the pelvic area for therapy or diagnosis?
Yes
No
If yes, explain:
Do you have or have you ever had (check all that apply):
None
Anemia
Anorexia
Appendicitis
Arthritis
Asthma
Bladder Infections
Blood Transfusions
Breast Milky Discharge
Breast Soreness
Breast Tenderness
Chest Pain
Chlamydia
Chronic Bronchitis
Chronic Headaches
Colitis
Color Blind
Diabetes
Dizziness
Epilepsy
Gallbladder Problems
Gonorrhea
Heart Disease
Hepatitis Type?
Herpes
Hirsutism (Excess Hair Growth)
Rheumatic Fever
High Blood Pressure
Immunization:German Measle
Kidney Infection
Liver Problems
Loss of Balance
Lupus
Measles:German
Measles:Regular
Neurological Problems
Nongonococcal Urethritis
Parasitic Infection
Pelvic Infection
Pneumonia
Poor Sense of Smell
Problems with Skin Pigmentation
Scarlet Fever
Seizures
Spastic Colon
Syphilis
Tuberculosis
Ulcers
Visual Disturbances
Vitiligo
Cancer?
Thyroid Problems?
Any Allergies: Please list:
None
Have you ever been treated for cancer?
Yes
No
If yes, explain therapy :
Within the last year, have you taken any prescription medications?
Yes
No
If yes, list all prescriptions and problems for which you were taking them:
Are you taking any over-the-counter medications on a regular basis?
Yes
No
If yes, list all medications and diagnoses:
Have you had a high fever (over 102 degrees F) during the past 3-4 months?
Yes
No
Do you use or have you ever used (check all that apply):
N/A
Alcohol
Cigarettes
How many glasses per week do you usually drink?
wine
beer
cocktails
Number of packs per day
How long have you smoked?
Recreational Drugs (Marijuana, Cocaine, others)
IV. SEXUAL HISTORY
Are you circumcised?
Yes
No
When you were a child, were both testes descended into the scrotum?
Yes
No
At what age did you begin shaving regularly or start to grow a beard?
How many times have you been married?
Have you ever produced a child with another partner?
Yes
No
N/A
If yes, how long did it take to produce a child?
Do you have trouble achieving and maintaining an erection?
Yes
No
Do you have trouble with ejaculations?
Yes
No
If yes,
N/A
Premature ejaculations
Retrograde ejaculations?
Do you feel that some of your ejaculate is deposited in the vagina?
Yes
No
Do you ever have orgasms without ejaculation during masturbation?
Yes
No
Do you have any discharge from the penis?
Yes
No
How many times per week do you and your partner now have intercourse?
How many times do you have intercourse around ovulation?
---
1-3
4-7
8+
don't know
Have you noticed a change in your sexual drive recently?
Yes
No
V. FAMILY HISTORY
Is there a family history of infertility?
Yes
No
N/A
If yes, who (list all members and relationship to you):
Is there a history of hormonal disorders in your family?
Yes
No
N/A
If yes, list who (relationship to you) and what type:
VI. HISTORY OF FERTILITY THERAPY
Have you been treated for infertility before?
Yes
No
N/A
If yes, who was your physician?
What drugs have you taken for infertility? Check all that apply:
clomiphene citrate (Sereophene, Clomid)
hMG (Pergonal)
tamoxifen
testolactone (Metrodin)
bromocriptine (Parlodel)
testosterone or Male Hormone
hCG (Profasi, A.P.L.)
fluoxymesterone (Halotestin)
GnRH or LHRH (Factrel)
urofollitropin or FSH
None
Other
Have you ever had varicocele repair?
Yes
No
N/A
If yes, when?
Have you ever had vasectomy reversal or repair?
Yes
No
N/A
If yes, when?
Have you and your partner ever tried artificial insemination?
Yes
No
N/A
If yes: using your sperm? donor sperm?
Have you and your partner ever tried in vitro fertilization?
Yes
No