Pacific in vitro fertilization institute

Pacific In Vitro Fertilization Institute
Patient Name: ____________________________
MALE HISTORY

Height: ___________________________
Have you been treated for infertility before: ____No _____Yes Physician(s): ______________________ Date:____________ Physician:______________________ Date:____________ Physician: ______________________ Have you had surgery for varicocele repair? ___No ___Yes Date:____________ Physician: ______________________ Do you have any children conceived with another partner? Do you have or have you ever had: (check all that apply) ____ Blood Transfusion (date____/____/____) ____
FERTILITY TESTING AND TREATMENT

What DRUGS have you taken for infertility? (Check all that apply)
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Other – Specify ___________________________________ What TESTING have you done for infertility: (Check all that apply) ____ Testicular Physician: ___________________________________ Physician: ___________________________________ Physician: ___________________________________ What TREATMENTS have you had for infertility? (Check all that apply) ____ Artificial Date last cycle__________ Physician:___________________________ Date last cycle__________ Physician:___________________________ SEMEN ANALYSIS Date: ____/____/____ Lab:_____________ mil/ml_____ %mot______ Act______ Date: ____/____/____ Lab:_____________ mil/ml_____ %mot______ Act______ Pacific In Vitro Fertilization Institute
Patient Name: ____________________________
MEDICAL HISTORY
Do you have any medical problems?
Type:______________________________ Date:____/____/____ Treatment: Type:______________________________ Date:____/____/____ Treatment: Are you allergic to any MEDICATION? ____No ____Yes – list all and describe reaction Medication ______________________ Reaction: _______________________________________________ Medication ______________________ Reaction: _______________________________________________ Are you allergic to any FOODS? ____Yes – list all and describe reaction Food ____________________________ Reaction: _______________________________________________ Food ____________________________ Reaction: _______________________________________________ Are you taking any PRESCRIPTION MEDICATIONS? Prescription: _____________________ For: _____________________________________________________ Prescription: _____________________ For: _____________________________________________________ Are you taking any OVER-THE-COUNTER MEDICATION? ____No Medication: _____________________ For: _____________________________________________________ Medication: _____________________ For: _____________________________________________________ Do you take any HERBAL MEDICATINS/VITAMINS or health food supplements? Medication: _____________________ For: _____________________________________________________
Medication: _____________________ For: _____________________________________________________
FAMILY HISTORY
List any members of your immediate family who have a history of infertility or breast cancer:
Relationship: _______________________ Condition:___________________ Treatment:__________________
SOCIAL HISTORY
How many caffeinated beverages (coffee, tea, soda) do you drink a day? _____________
How many/day:__________ How many years:_____________ started:_____________ Quitting? ______________ #Beer/week_____ #Wine per week_____ #Liquor/week_____ Do you use marijuana, cocaine or other simular drugs? ____No ____Yes - describe________________________________ Do you exercise?
PHYSICIAN NOTES:_________________________________________________________________________________
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Source: http://www.pacificinvitro.com/pdf/MaleHistoryForm.pdf