MALE MEDICAL HISTORY AND INFORMATION
Complete with your partner if applicable.
Have you been evaluated by a urologist?
Yes
No
Have you previously conceived with another woman?
Yes:How many times?
No: Birth control used?
Yes
No
Do you have difficulty with erections?
Yes
No
Do you have premature ejaculation?
Yes
No
Do you have retrograde ejaculation of sperm into the bladder?
Yes
No
Any prior exposure to sexually transmitted diseases or infections?
No
Yes (check all that apply)
Chlamydia - date
Gonorrhea - date
Herpes - date
Genital warts/HPV - date
Syphilis - date
HIV/AIDS - date
Hepatitis - date
Have you had a history of undescended testicles?
No
Yes - One side
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 been diagnosed with any of the following diseases?
Diabetes Mellitus
Yes
No
Cancer
Yes
No
Multiple Sclerosis
Yes
No
Other neurologic problems
Yes
No
Prostatic infections
Yes
No
Urinary infections
Yes
No
High Blood Pressure
Yes
No
If yes, any medications ?
Have you had any inury or trauma to the genitilia( testes/penis) ?
Yes
No
Have you had any fever in the last 3 months?
Yes
No
Have you had a vasectomy?
No
Yes, Date:
If yes, have you had a vasectomy reversal?
No
Yes, Date:
Have you had surgery for varicocele repair?
Yes
No
Have you had hernia surgery?
Yes
No
Did you undergo any bladder or penis surgery as a child?
Yes
No
Are you exposed to prolonged heat in the workplace?
Yes
No
Are you exposed to any radiation or harmful chemicals in the workplace?
Yes
No
Have you had chemotherapy for cancer?
Yes
No
Are you allergic to any medications?
No
Yes (Please list and describe reactions)
List your current medication:
List any current medical problem(s):
Social History:
Disorders in Your Family:
I confirm that I have reviewed the information above.
Date:
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