|
Male Health Questionnaire
|
|
|
To provide you with the best possible care, we ask that you fill out the following questionnaire.
|
|
|
Try to answer the questions as honestly as possible. If any questions do not apply to you simply state N/A.
|
|
|
Do not leave any questions blank.
|
|
|
Demographics
|
|
|
Marital status:
|
If other marital status
|
|
Partner / Spouse:
|
Date of Birth of your Partner/Spouse AND age:
|
|
Partner/Spouse Cell Phone:
|
Partner/Spouse Email address:
|
|
If you are married or in a committed relationship, please list duration in years _____
|
Do you have children?
|
|
Are you interested in having children in the future?
|
|
|
|
|
|
Are you Medicare eligible? (age 65+)
|
Are you on Medicare Disability?
|
|
Reason For Visit
|
|
|
Click if you are here for infertility/Azospermia/Oligospermia
|
Other Reasons for Visit
• • •
|
|
Other:
|
|
|
Infertility Questionnaire
|
|
|
Questions for HIM
|
|
|
How many years have you been trying to conceive?
|
|
|
Number of pregnancies carried to term and delivered with current partner:
|
|
|
Number of miscarriages with current partner:
|
Number of planned abortions with current partner:
|
|
Number of pregnancies between you and your current partner?
|
|
|
Number of pregnancies between you and previous partner(s)?
|
|
|
Number of pregnancies carried to term and delivered with previous partner(s):
|
Number of miscarriages with previous partner(s):
|
|
Number of planned abortions with previous partner(s):
|
|
|
Method of birth control, if used in past (select all that apply):
• • •
|
How many times each week (on average) do you have intercourse?
|
|
Types of lubricant, if used:
|
|
|
Have you had prior infertility treatments?
|
If yes, please list infertility treatments:
|
|
FAMILY HISTORY
|
|
|
How many blood related brothers do you have?
|
How many blood related sisters do you have?
|
|
Have any of your brothers or sisters had trouble conceiving?
|
If yes, who?
|
|
What problem did they have conceiving?
|
|
|
Are there any adopted children in your family?
|
If so, who has adopted children?
|
|
Any miscarriages in the immediate family?
|
Did your parents have trouble conceiving you or your sibling(s)?
|
|
GENETIC INFERTILITY SCREENING
|
|
|
Do you have any of the follow ancestry?
• • •
|
Does your partner have any of the following ancestry?
• • •
|
|
Click if you have children
|
|
|
Are the children you and your partner have together healthy?
|
Are the children you and your previous partner(s) have together healthy?
|
|
Are the children your partner and their previous partner healthy?
|
|
|
Do the children you and your partner have together have birth defects, genetic conditions or severe medical problems??
|
Do the children you and your previous partner(s) have together have birth defects, genetic conditions or severe medical problem?
|
|
Do the children your partner and their previous partner have birth defects, genetic conditions or severe medical problems?
|
If yes, please describe:
|
|
Do the children you and your partner have together have developmental delay, learning disabilities or mental retardation?
|
|
|
Do the children you and your previous partner(s) have together have developmental delay or learning disabilities?
|
Do the children your partner and their previous partner have developmental delay, learning disabilities or mental retardation?
|
|
If yes, please describe:
|
|
|
QUESTIONS FOR HER
|
|
|
How many blood related brothers do you have?
|
How many blood related sisters do you have?
|
|
Number of pregnancies between you and previous partner(s)?
|
|
|
Number of pregnancies carried to term and delivered with previous partner(s):
|
Number of miscarriages with previous partner(s):
|
|
Number of planned abortions with previous partner(s):
|
|
|
Do you have regular menstrual cycles?
|
|
|
Do you have any medical problems?
|
If yes, please describe:
|
|
Which of the following fertility tests have been performed? (Select all that apply)
• • •
|
What were the results of those fertility tests?
|
|
Click if you have used the treatment: Clomid
|
# of cycles used and when:
|
|
Click if you have used the treatment: IUI
|
# of cycles used and when:
|
|
Click if you have used the treatment: IVF
|
# of cycles used and when:
|
|
Click if you have used the treatment: IVF/ICSI
|
# of cycles used and when:
|
|
Has anyone in your family had trouble conceiving?
|
|
|
If yes, who? What problem?
|
|
|
MEDICAL HISTORY
|
|
|
Do you have a history of any of the following conditions?
|
|
|
High Blood Pressure
|
Elevated Cholesterol
|
|
Heart Attacks
|
Diabetes
|
|
Stroke
|
Cancer
|
|
Kidney Stones
|
Ulcers
|
|
Multiple Sclerosis
|
Bronchitis
|
|
Pneumonia
|
Other:
|
|
Please list all other medical issues:
|
|
|
Do you have any allergies?
|
Please list all Allergies
|
|
Are you on any medications currently?
|
Please list Name/ Dosage/ Frequency (How Often)
|
|
1. Medication Name, Strength/Dose, Frequency:
|
|
|
2. Medication Name, Strength/Dose, Frequency:
|
|
|
3. Medication Name, Strength/Dose, Frequency:
|
|
|
4. Medication Name, Strength/Dose, Frequency:
|
|
|
If Other (medication name, dose/strength, frequency)
|
|
|
Please list all supplements you are currently taking (if none please type "None").
|
|
|
UROLOGICAL HISTORY
|
|
|
Have you ever had any of the following?
|
|
|
Undescended testicles at birth?
|
If yes, which side(s)?
|
|
Mumps after puberty with painful testes?
|
Blood in your urine?
|
|
Injury to the testicles that needed hospitalization
|
|
|
Blood in your ejaculate
|
Green or yellow discharge from the penis
|
|
|
|
|
PLEASE SELECT IF YOU HAVE CONCERNS REGARDING YOUR ERECTION
|
How do you rate your confidence that you could get and keep an erection?
|
|
When you had erections with sexual stimulation, how often were your erections hard enough for penetration?
|
During sexual intercourse, how often were you able to maintain an erection after you had penetrated your partner?
|
|
During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?
|
When you attempted sexual intercourse, how often was it satisfactory for you?
|
|
|
|
|
Do you ejaculate before your partner is ready?
|
|
|
Do you have difficulty ejaculating?
|
|
|
PLEASE SELECT IF YOU ARE EXPERIENCING PAIN
|
If Yes, where?
• • •
|
|
On a scale from 1-10 describe how intense your pain gets at its worst:
|
Describe what the pain feels like. Use the words that best describe the pain.
• • •
|
|
What causes or increases the pain?
|
What relieves the pain?
|
|
On a scale from 1-10 describe how the pain has changed since treatment has started. (Try to pick the average pain).
|
|
|
PLEASE SELECT IF YOU ARE HAVING PROBLEMS WITH URINATION
|
If Yes, select all that apply
• • •
|
|
Over the past month, how often have you had a sensation of not emptying your bladder completely after you finish urinating?
|
Over the past month, how often have you had to urinate again less than two hours after you finished urinating?
|
|
Over the past month, how often have you found you stopped and started again several times when you urinated?
|
Over the past month, how difficult have you found it to postpone urination?
|
|
Over the past month, how often have you had a weak urinary stream?
|
Over the past month, how often have you had to push or strain to begin urination?
|
|
Over the past month, how many times did you most typically get up to urinate from the time you went to bed until morning?
|
If you were to spend the rest of your life with your urinary condition the way it is now, how would you feel?
|
|
PLEASE SELECT IF YOU HAVE CONCERNS ABOUT YOUR TESTOSTERONE LEVELS
|
Do you have a decrease in libido (sex drive)?
|
|
Do you have a lack of energy?
|
Do you have a decrease in strength/endurance?
|
|
Have you lost height?
|
Have you noticed a decreased "enjoyment of life"?
|
|
Are you sad and/or grumpy?
|
Are your erections less strong?
|
|
Have you noticed a recent deterioration in your ability to play sports?
|
Are you falling asleep after dinner?
|
|
Has there been a recent deterioration in your work performance?
|
|
|
Have you ever had any of the following?
|
|
|
Urinary Tract Infection (UTI)
|
Infection of the prostate (Prostatitis)
|
|
Infection of the epididymis (Epididymititis)
|
Venereal disease(s) (Sexually transmitted disease)
|
|
Click to indicate diseases contracted
|
|
|
Gonorrhea
|
Date:
|
|
Syphilis
|
Date:
|
|
Herpes
|
Date:
|
|
Chlamydia
|
Date:
|
|
Genital Warts
|
Date:
|
|
Other
|
List other______
|
|
Date:
|
|
|
SURGICAL HISTORY
|
|
|
Have you ever had any of the following?
|
|
|
A hernia surgery?
|
If yes, which side(s)?
|
|
Date:
|
|
|
Penis or bladder operation as a child
|
Date:
|
|
Abdominal/Pelvic Surgery
|
Date:
|
|
Back Surgery
|
Date:
|
|
Vasectomy
|
Date:
|
|
Vasectomy Reversal
|
Date:
|
|
Surgery for varicoceles
|
Date:
|
|
Surgery for hydroceles
|
Date:
|
|
Surgery for scrotal cysts
|
Date:
|
|
Testicle Removal (Orchiectomy)
|
Date:
|
|
Surgery to lower undecended testicles (Orchiopexy)
|
|
|
Date:
|
Infertility Surgery or Sperm Retrieval?
|
|
Click if YES for Infertility Surgery or Sperm Retrieval
|
|
|
Testicular Sperm Aspiration (TESA)
|
Date:
|
|
Microdissection Testicular Sperm Extraction (mTESE)
|
|
|
Date:
|
|
|
Epididymal Sperm Aspiration
|
Date:
|
|
TURED
|
Date:
|
|
Electroejaculation
|
Date:
|
|
Prostate surgery?
|
|
|
Click if YES for Prostate surgery
|
|
|
TUIP/TURP, laser or other
|
Date:
|
|
Radical prostatectomy
|
Date:
|
|
Radioactive seed implant:
|
Date:
|
|
Prostate needle biopsy
|
Date:
|
|
Any other surgeries? (wisdom teeth, appendix, tonsillectomy, LASIK, etc.)
|
|
|
Surgery type & date:
|
Surgery type & date:
|
|
Surgery type & date:
|
Surgery type & date:
|
|
Surgery type & date:
|
Surgery type & date:
|
