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Occupation:______________________ Referred by: _______________
Reproductive History:
1. Do you have any children? Yes/ No, If yes how many ____Ages_________
2. Duration of unprotected intercourse?________________________________
3. How old is your partner?_________yrs
4. Does your partner have any children? Yes/ No
5. Has your partner had any miscarriages/abortions?
If yes, detail________________________________________________ 6. Has your partner been evaluated for this problem? Yes/ No, If yes, results_______________________________________________
Sexual History:
1. Timing/ frequency of intercourse?___________________________________
2. Problems with erections? If yes detail_______________________________
3. Problems with ejaculations?_______________________________________ 4. Use of lubricants? Yes/ No, If yes name_______________________________
Developmental History:
1. Onset of Puberty___________________________________________
2. Age when you started shaving._____ Do you shave everyday? Yes/ No
3. Any delay in development? Yes/ No, If yes detail__________________ Male infertility questionnaire
Page two
Medical History:

1. Any childhood illnesses? (Circle any that apply) None_____
g. other__________________________________________________ Notes____________________________________________________________________________________________________________________ 2. Any other illnesses? ( Circle all that apply) None______ e. other_________________________________ Notes_____________________________________________________________________________________________________________________ 3. Medications: (Circle all that apply) None_____ Have you ever been on Notes_____________________________________________________________________________________________________________________ Please list all the medications you are on, including over the counter and herbal medications. None_________ Notes _______________________________________________________ ____________________________________________________________ Male infertility questionnaire Page three Surgical History:
h. epididymal surgery i. Testicular biopsy Notes _________________________________________________________ ______________________________________________________________ List all other surgeries and their complications if any: Personal History: (Please circle one)
Do you or have you ever had alcohol? Yes/ No Do you or have you ever used recreational drugs? Notes____________________________________________________ Any additional comments__________________________________________ ______________________________________________________________ ______________________________________________________________ Patient Signature:__________________________________ Dated______________ Name:_______________________________ Age:____________________ Urinalysis:
eukocytes:____Nitrite:____Urobilinogen_____Protein:______Blood:___________Sp.Gravity:________pH:________ K etone:_______Bilirubin:_______Glucose:__________WBC:_______RBC:_______Yeist:______Bacteria:_________ Ep.Cells:_______Crystals:________Casts:_________Other:__________
Physical Examination

1. General ( means normal) BP:__________ Pulse:_______ RR:________ Temp:_________ Height:___________ Weight:_____________ a. Nutrition_____ b. body habitus_______ d. gynecomastia_______ e. secondary sexual characters__________ Urethral opening_______ Plaques_______ Size________ Semen Analysis: Has a semen analysis been done? If yes results.
Notes:__________________________________________________________ _________________________________________________________ _________________________________________________________ Impression: 1.________________________ 2.________________________ 2._____________________________ 3._______________________ Signed ______________________________ Date: ___________________


Hchs section 6

PREGNANCY IN ADOLESCENCE: INFORMATION FOR PARENTS AND EDUCATORS By Adena B. Meyers, PhDIllinois State University The term adolescent pregnancy brings to mind a number of related issues such as adolescentsexuality, premarital sex, birth control, abortion, adolescent childbearing, adolescent parenthood,unplanned pregnancy, unintended birth, out-of-wedlock birth, and single motherhood. M

PROCEDURE FOR DEVELOPING AND APPROVING APT COMMON PROPOSALS FOR ITU WORLD CONFERENCE ON INTERNATIONAL TELECOMMUNICATIONS Introduction The objective of the APT preparatory Group for the ITU World Conference on International Telecommunications (WCIT) is to develop proposals that have a greater chance of success through the support of a number of APT Members. These proposals can take

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