Male Patient Form - Reproduction Health Center

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.#

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/AExcessive HeatToxic FumesChemicalsNuclear RadiationOther

Weight Height Blood Type(if known)

Have you lost greater than 20 pounds of weight in the last year?YesNo

Do you follow a particular food diet or have any special dietary habits? YesNo

List the forms and frequency of regular vigorous exercise (swimming,cycling,running) and age at which you began them:

Do you frequently take saunas or steam baths?YesNo

Have you ever had surgery in the pelvic area? YesNo

Semen AnalysisChlamydia TestMycoplasma TestAntibody TestHamster Egg TestChromosome TestTesticular BiopsyX-ray or Ultrasound of TestesHormonal Tests (FSH,LH,prolactin,testosterone)Thyroid TestsOther- SpecifyNone

Is your partner currently seeing a doctor for evaluation of infertility?YesNo

Does the doctor feel that your partner has an infertility problem?YesNoN/A

Has she ever had children with another man?YesNo

Do you have any allergies to any medications?YesNo

Have you ever received X-rays in the pelvic area for therapy or diagnosis?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?

Any Allergies: Please list:

None

Have you ever been treated for cancer?
YesNo

Within the last year, have you taken any prescription medications?YesNo

Are you taking any over-the-counter medications on a regular basis?YesNo

Have you had a high fever (over 102 degrees F) during the past 3-4 months?YesNo

Do you use or have you ever used (check all that apply):N/AAlcoholCigarettes

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)

Are you circumcised? YesNo

When you were a child, were both testes descended into the scrotum?YesNo

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? YesNoN/A

Do you have trouble achieving and maintaining an erection? YesNo

Do you feel that some of your ejaculate is deposited in the vagina? YesNo

Do you ever have orgasms without ejaculation during masturbation? YesNo

Do you have any discharge from the penis? YesNo

How many times per week do you and your partner now have intercourse?

How many times do you have intercourse around ovulation?

Have you noticed a change in your sexual drive recently?YesNo

Is there a family history of infertility? YesNoN/A

Is there a history of hormonal disorders in your family? YesNoN/A

Have you been treated for infertility before?YesNoN/A

What drugs have you taken for infertility? Check all that apply: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

Have you ever had varicocele repair? YesNoN/A

Have you ever had vasectomy reversal or repair?YesNoN/A

Have you and your partner ever tried artificial insemination?YesNoN/A

Have you and your partner ever tried in vitro fertilization? YesNo

(520) 733-0083

Male Patient Form - Glendale AZ