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Fertility Evaluation Questionnaire
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| Date _______________________ Referred by _______________________________________ |
| Name _____________________________________________________ Age _______________ |
| In your own words, explain your concern or problem with fertility ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ |
| In order to understand the exact nature and determine the cause of your problem, we ask that you complete this questionnaire. Please answer the following questions by indicating your response. Feel free to add information that you feel is important. |
| MARITAL HISTORY |
| How long have you been married? _________________________________________________ How long have you been actively trying to have a baby? ______________________________ Wife's obstetrician ______________________________________________________________ Are there any fertility problems with your wife? ______________________________________ Wife's age _______________ Previous pregnancies __________________________________ |
| CHILDHOOD |
Do you have a history of:
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| MEDICAL HISTORY |
Do you have a history of:
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| CURRENT & PAST MEDICATIONS/DRUGS |
| Prescription drugs ____________________________________________________________ Steroids or body building drugs _________________________________________________ Chemotherapy _______________________________________________________________ Recreational drugs ___________________________________________________________ Cimetidine __________________________________________________________________ Antibiotics __________________________________________________________________ Tobacco: Have you ever smoked: ______ Yes ______ No Presently smoking ________________ If yes, how long ____________ If you quit, when _______________________________ How much: Daily ______________________ or Weekly ______________________ |
| ENVIRONMENTAL HISTORY |
| Current occupation ___________________________________________________________ Past or present exposure to: Radiation ________________________________________________________________ Chemicals ________________________________________________________________ Known pollutants __________________________________________________________ Themal exposure (extreme or excessive heat): Occupational ___________ Hot Tubs __________ Other _____________________ |
| SEXUAL ACTIVITY/HISTORY |
| Average sexual intercourse: Week ___________________ Month ___________________ Other _____________________________________________________________________ Have you ever fathered a child or been responsible for conception? ___________________ Have you had a vasectomy reversal? ____________________________________________ |
| ERECTILE DYSFUNCTION |
| Do you have: Failure to achieve erection _____________________________________________________ Failure to maintain an erection __________________________________________________ Failure to ejaculate/achieve orgasm _____________________________________________ Decreased desire / No desire for sex _____________________________________________ Other ______________________________________________________________________
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Fertility Evaluation
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| Patient Name ___________________________________________ Date _______________ |
| PHYSICAL EXAMINATION |
| Body habitus _________________________________________________________________ Hair distribution _______________________________________________________________ Gynecomastia ________________________________________________________________ Other _______________________________________________________________________ Penis: Curvature ____________________________________________________________________ Plaques ______________________________________________________________________ Meatal position ________________________________________________________________ Scrotum: Testicular size and consistency __________________________________________________ Vas deferens _________________________________________________________________ Varicocele ____________________________________________________________________ |
| REVIEW OF HISTORY |
| ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ |
| PLAN |
| ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ _____ Semen analysis _____ Testosterone _____ Prolactin _____ LH/FSH _____ Chem 23 _____ Duplex scrotal ultrasound Other: _______________________________________ |
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Copyright © 2010 Urology Specialists, S.C. All rights reserved. Last Updated: 08 February 2010 |