The Reproductive Medicine Group (Male Reproductive History)

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		Provider Name

Date testing was last performed:

What were your results?

Within normal limits Abnormal Other

Date: Have you had a vasectomy reversal? Yes No

Which family members have had difficulty conceiving?

Have you been evaluated by a urologist? Yes No

Have you previously conceived with another woman? Yes No

Have you previously conceived using a Gestational Surrogate? Yes No

Have you had a semen analysis? Yes No

Do you have difficulty with erections? Yes No

Do you have retrograde ejaculation of sperm into the bladder? Yes No

Have you had any of the following STDs?

Partner has not been tested for sexually transmitted diseases or pelvic infections

Chlamydia

Gonorrhea

Genital warts

Hepatitis

Herpes

HIV / AIDS

Syphilis

Other STD testing

Have you had a history of undescended testicles? No Yes (1 side) Yes (Both)

Do you have scrotal or testicular pain? Yes No

Did you have the mumps after puberty? Yes No

Have you had prior injury to your testicles requiring hospitalization? Yes No

Have you ever been diagnosed with any of the following diseases?

Diabetes Multiple sclerosis Prostatic infections High blood pressure Urinary infections

Have you had a fever in the past 3 months? Yes No

Have you had a vasectomy? Yes No

Have you had surgery for varicocele repair? Yes No

Have you had hernia surgery? Yes No

Did you undergo any bladder or penis surgery? Yes No

Are you exposed to prolonged heat in the workplace? Yes No

Are you exposed to any radiation in the workplace? Yes No

Are you exposed to any harmful chemicals in the workplace? Yes No

Do you use hot tubs regularly? Yes No

Have you had chemotherapy for cancer? Yes No

How many caffeinated beverages do you drink per day?

Do you smoke cigarettes: Currently In the past Never

How many packs per week?

How many years have you been smoking?

If you smoke cigars, how many do you smoke per week?

Do you drink alcohol? Yes No

Do you use drugs? Yes No

Please describe:

Have any of your family members had difficulty conceiving a child?

Yes No Unknown

What is your Ethnicity?

Asian Black/African American Hispanic Pacific Islander Native American White/Caucasian Other Unknown Does not want to disclose

Please mark all conditions that your family members have had.

Family History Unknown No Known Family Disorders

Bloom Syndrome

Bone / Skeletal Defects

Canavan Disease

Color Blindness

Cystic Fibrosis

Deafness / Blindness

Developmental Delay

Down Syndrome

Dwarfism

Familial Dysautonomia

Fanconi Anemia

Galactosemia

Gaucher Disease

Heart Defect from Birth

Hemochromatosis

Hemophilia

Hypertension

Learning Problems

Marfan Syndrome

Muscular Dystrophy

Neural Tube Defects

Niemann-Pick Disease

Sickle Cell Anemia

Tay-Sachs Disease

Neurologic (brain/spine)

Polycystic Kidney Disease

Other Chromosome Defect

Other Significant Medical Condition:

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Online Health Forms by PatientLink® Enterprises Inc.
Oklahoma City, OK 73189
Form Number 1255

This form is meant to be submitted online. Please return to the form on your computer, answer all questions, and click the ‘Submit’ button when completed.

Past Medical History

Pregnancy / Birth

Diagnostic

Social History

Surgical History

Family History

Physical Symptoms

Male Partner History

Please complete this section with your male partner if applicable. All questions in this section are worded as though your male partner were answering the question.