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Patient Portal
Male Patient History
"
*
" indicates required fields
I. Identify Information
Date
*
DD dash MM dash YYYY
Name
*
First
Partner's Name
*
First
Address
*
Telephone Number (Day)
*
Telephone Number (Evening)
*
Date of Birth
*
DD dash MM dash YYYY
Partner's Date of Birth
*
DD dash MM dash YYYY
Duration of Relationship
*
Duration of Identity
*
II. Travel / Work and General Background
Title's
*
First
Location
*
Brief Description
*
Number of Year's Employed
*
Title's
*
First
Location
*
Brief Description
*
Number of Year's Employed
*
Title's
*
First
Location
*
Brief Description
*
Number of Year's Employed
*
Are you or have ever been exposed to any of the following during employment or military service
Heat
Chemicals
Toxic Fumes
Nuclear Radiation
Others
Other Specify
III. Medical History
weight
*
Height
*
Blood Type (If Known)
*
Have you ever 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 habbits
Yes
No
If yes, specify
List the forms and frequency of regular vigorous exercise (Swimming, cycling, running) and the age you began
Exercise
Hours/Week
Age
Exercise
Hours/Week
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:
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):
Anemia
Appendicitis
Arthritis
BloodTransfusion
Breast Milky Discharge
Breast Soreness
Breast Tenderness
Chlamydia
Chronic Bronchitis
Chronic Headaches
Colitis
Cystic Fibrosis
Diabetes
Dizziness
Cancer ?
Epilepsy
Gallbladder Problems
Gonorrhea
Heart Disease
Hepatitis
Herpes
High Blood Pressure
Kidney Infection
Liver Problems
Loss of Balance
Measles: German
Measles: Regular
Mumps
Mumps with Testes Involved
Neurological Problems
Nongonococcal Urethritis
Parasitic Infection
Pneumonia
Prostatitis
Rheumatic Fever
Scarlet Fever
Seizures
Syphilis
Testes Infection
Testes Injury
Testes Tumor
Thyroid Problems
Tuber Culosis
Ulcers
Visual Disturbances
Any Allergies?
If Cancer? Specify
Any Allergies? List
IV. HISTORY of FERTILITY THERAPY
Have you been treated for infertility before?
Yes
No
If yes, who was your physician?
What cause of infertility was diagnosed?
What drugs have you taken for infertility? Check all that apply:
clomiphene citrate (Serophene®,Clomid®)
hMG (Pergonal®)
tamoxifen
testolactone
bromocriptine (parlodel®)
testosterone or Male Hormone
hCG (Profasi®,A.P.L.®).
fluoxymesterone (Halotestin®)
GnRH or LHRH (Factrel®)
urofollitropin or FSH (Metrodin®)
None
Others? Specify
Others? Specify
Have you ever had varicocele repair?
Yes
No
If yes, when?
Have you ever had vasectomy reversal or repair?
Yes
No
If yes, when?
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
If yes, when and explain:
Which of the following tests have you had performed? Check all that apply and the results if known:
Semen Analysis
Semen Analysis
When?
Results:
Chlamydia Test
Chlamydia Test
When?
Results:
Mycoplasma Test
Mycoplasma Test
When?
Results:
AntibodyTest
AntibodyTest
When?
Results:
Hamster Egg Test
Hamster Egg Test
When?
Results:
Chromosome Test
Chromosome Test
When?
Results:
Testicular Biopsy
Testicular Biopsy
When?
Results:
X-ray or Ultrasound of Testes
X-ray or Ultrasound of Testes
When?
Results:
Hormonal Tests (FSH, LH, prolactin, testosterone)
Hormonal Tests (FSH, LH, prolactin, testosterone)
When?
Results:
Thyroid Tests
Thyroid Tests
When?
Results:
Other-Specify
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, what is the diagnosis and how is she being treated?
Has she ever had children with another man?
Yes
No
If yes, when?
