Microsoft word - infertility packet.doc

Urology Clinic of Utah Valley
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MEDICAL HISTORY FORM FOR INFERTILITY
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In order to assess your Infertility and to give you the best medical treatment possible, we
would appreciate you completing the following questionnaire. There is also a section for
your partner to complete as well. All information will be held in strict confidence.
Please complete the entire questionnaire. Thank you.
PATIENT (Male)

Name: __________________________________________________________________
Address: ________________________________________________________________
Home Phone: ________________________ Work Phone: ________________________
Birth Date: __________________________ Age: _______________________________
Years Married: _______________________ Years Trying to Conceive: ______________
Referring Physician: _______________________________ Phone: _________________
Birth Control Method: _____________________________________________________
Previous pregnancy with spouse/partner:
Live Births (0-9) _______Miscarriages (0-9) _______ Abortions (0-9) _______ Previous pregnancy with someone other than your spouse or partner: Live Births (0-9) _______Miscarriages (0-9) _______ Abortions (0-9) _______ Infertility Questionnaire
Page 2
MEDICAL HISTORY:
1.
Did you have undescended testicles at birth? At what age did you start to shave? __________ Approximately at what age did you start going through puberty? __________ ____________________________________________________________ Have you ever had urinary tract infections? Have you ever had blood in your ejaculate (semen)? Yes ______ Have you ever had a white, green, or yellow (tying off dilated veins to the scrotum) Have you ever had trauma (injury) to your testicles? Yes ______ If yes, Please specify: ________________________________________________ MEDICATIONS, DRUGS, GONADOTOXINS, OCCUPATIONAL HAZARDS:
If yes, how long (years) ______, how many packs daily ______. Do you now or have you ever used any of the following drugs? Please list any prescription medications you currently or frequently take: __________________________________________________________________ __________________________________________________________________ Please list any over-the-counter medications you currently or frequently take: __________________________________________________________________ __________________________________________________________________ If yes, please specify: _____________________________________________ Do you frequently take hot baths, saunas, or steam baths or exposed to temperature extremes (hot or cold) Have you ever been exposed to chemicals, solvents and their fumes, or any toxins/poisons (e.g. Pesticides)? SEXUAL HISTORY:
Do you have any problems getting or maintaining If yes, please specify ______________________________________________ Do you use any form of lubrication for intercourse? Yes ______ Is intercourse ever painful for you or your partner? Yes ______ If yes, please specify ______________________________________________
FAMILY HISTORY:

Are there any problems with Infertility or physical If yes, please specify ______________________________________________
REVIEW OF SYSTEMS:

1.
Do you frequently get colds, upper respiratory tract Have you had a fever of viral illness recently ? If yes, please specify ______________________________________________ Are you overly sensitive to heat or cold? Do you have any testicular pain of discomfort?
Infertility Questionnaire
Page 5
PARTNER (Female)

Name: __________________________________________________________________
Date of Birth: ____________________________ Age: __________________________ Previous pregnancies with any other partners: (not including spouse) ________________ Live births (0-9) ______ Miscarriages (0-9) _______ Abortions (0-9) _______ List any history of medical gynecological problems (e.g. pelvic or vaginal infections, endometriosis, etc.) ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Do you have regular menstrual cycles/periods? Have you been evaluated for infertility? ________________________________________________________________________ ________________________________________________________________________ __________________________________________________ Please list any treatment for infertility a dates (i.e. Clomid, Pergonal, Intrauterine insemination, etc.) ________________________________________________________________________ ________________________________________________________________________

Source: http://utahvalleyurology.net/PDF/Infertility_Packet_type.pdf