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Maleinfertility_ucna

MALE INFERTILITY
PATIENT QUESTIONNAIRE
UROLOGIC CLINICS OF NORTH ALABAMA
Name:__________________________Age:________Race:__________
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:
L
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: ___________________

Source: http://www.ucna.com/maleinfertility_ucna.pdf

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