Reproductive health center

REPRODUCTIVE HEALTH CENTER
MALE PATIENT HISTORY
I. IDENTIFYING INFORMATION
Name_______________________________ Partner's Name_______________________________ Address__________________________________________________________________________ Telephone Number – Day:( )______________ Date of Birth______ Partner's Date of Birth______ Duration of Relationship_______ Duration of Infertility, if present______________________________________________ Insurance Company___________________________ Insurance I.D.#_____________________ II. TRAVEL/WORK AND GENERAL BACKGROUND
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: Other Specify:______________________________________________________________ III. MEDICAL HISTORY
Weight________ Height________ BloodType(if known)______ Have you lost greater than 20 pounds of weight in the last year? yes no If yes, specify:_______________________________________________________________ List the forms and frequency of regular vigorous exercise (swimming,cycling,running) and the age you began them: Exercise________ Hrs/wk______ Age____ Exercise________ Hrs/wk______ Age____ 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? Hormonal Tests (FSH,LH,prolactin,testosterone) When? 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 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 If yes, explain:_______________________________________________________________ Do you have or have you ever had (check all that apply): Any Allergies: Please list: ______________________ __________________________ __________________________ ______________________ 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) Do you use or have you ever used (check all that apply): __Alcohol - How many glasses per week do you usually drink? wine beer cocktails __Cigarettes - Number of packs per day ____ How long have you smoked?_______ Recreational Drugs (Marijuana, Cocaine, others)____________________________________ IV. SEXUAL HISTORY
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 If yes, how long did it take to produce a child? ________ Have you ever tried to produce a child with another partner? yes no Do you have trouble achieving and maintaining an erection? yes no Do you have trouble with ejaculations? yes no If yes, __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? ________ Have you noticed a change in your sexual drive recently? yes no V. FAMILY HISTORY
Is there a family history of infertility? yes no If yes, who (list all members and relationship to you): _________________________________________________________________________________ Is there a history of hormonal disorders in your family? yes no If yes, list who (relationship to you) and what type: _________________________________________________________________________________ VI. HISTORY OF FERTILITY THERAPY
Have you been treated for infertility before? yes no If yes, who was your physician?____________________________________________________ What drugs have you taken for infertility? Check all that apply: __clomiphene citrate (Serophene, Clomid) Have you ever had varicocele repair? yes no If yes, when? _________________________________________________________________________________ Have you ever had vasectomy reversal or repair? yes no _________________________________________________________________________________ Have you and your partner ever tried artificial insemination? yes no If yes: using your sperm? donor sperm? _________________________________________________________________________________ Have you and your partner ever tried in vitro fertilization? yes no

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