Male Medical Questionnaire
Male Patient History
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Fertility History
How long have you and your present partner been trying to conceive?
Have you ever been infertile with a past partner
Yes
No
If yes, how long?
Have you ever fathered a pregnancy before
Yes
No
Have you had any of the following tests performed (Check all that apply)
Test
Date
Result
Semen Analysis
Antisperm
Fertility
Hormone Tests
Urological exam
Fertility or Hormonal treatment
Medical History
Do you have or have you ever had (Check all that apply
Abnormal Puberty
Anemia
Appendicitis
Arthritis
Blood Transfusions
Cancer
Chronic Headaches
Colitis
Mumps
Diabetes
Gallbladder Problems
Heart Disease
Hepatitis
High Blood Pressure
HIV
Liver Problems
Migraine Headaches
Kidney Infections
Neurological Problems
Pneumonia
Rheumatic Fever
Rubella (German Measles)
Scarlet Fever
Seizures
Thyroid Problems
Tuberculosis (TB)
Ulcers
Vision Problems
Are you allergic to any medications?
Yes
No
if yes, what:
Have you ever had surgery before
Yes
No
Date and Type:
Have you ever had an injury to your genitals
Yes
No
Specify:
Have you ever had any of the following (Check all that apply)
Gonorrhea
Chlamydia
Venereal Warts
Genital Herpes
Syphilis
Prostatitis
Exposure to Radiation
Prolonged exposure to chemicals
Testosterone use
Social History
Please list current or most recent
Do you drink alcohol
Yes
No
if yes, how many per week?
Do you smoke
Yes
No
if yes, number of cigarettes per day?
For how long?
Do you now or have you ever used illicit drugs
Yes
No
if yes, specify:
Do you have an exercise program
Yes
No
if yes, Type:
Numbers per week?
Are you on a special diet?
Yes
No
if yes, specify:
What is your height:
Current Weight:
Ideal weight:
What is your blood type, if known?
Yes
No
Have you had more than a 10-pound gain/loss this pass year
Yes
No
How much?
Family History
Do any family members have significant health problems or inherited diseases?
Yes
NO
Check all that apply
Birth Defects
Brain/Spinal Defects
Cancer
Cystic Fibrosis
Diabetes
Down Syndrome
Fragile X Syndrome
Heart Disease
Hemophilia
High Blood Pressure
Muscular Dystrophy
Sickle Cell Disease
Tay-Sachs Disease
Thalassemia
Thyroid Disease
Other Genetic Conditions
Medications and Testosterone Use
What medications are you taking daily?
Have you taken Testosterone?
Yes
No
IF yes
oral
intermuscular injection
How long?
Last dose?
Submit
Should be Empty: