MALE REPRODUCTION QUESTIONNAIRE
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1 Bruce R. Gilbert, M.D., Ph.D. Director, Reproductive and Sexual Medicine Smith Institute For Urology North Shore - Long Island Jewish Health System Date: MALE REPRODUCTION QUESTIONNAIRE Please fill out the following form as honestly and completely as you can. The purpose of this information is to help assess your reproductive potential. Your thoroughness in its completion is essential to evaluation and treatment. All information will be held in strict confidence. Please bring this form with you on your first visit. A. Identification: Name: Address: Birthdate: Ethnic Origin: Age: Birthplace: Telephone (home): Telephone (work): Referred by: Marital Status: single divorced married separated widowed Partners name: Her age: B. Fertility History: 1. For how many months have you been trying to achieve pregnancy with your current partner? 2. Have you achieved pregnancy with your current partner in the past? If yes, please give dates (a-d) and note any adverse outcome (e-h): (a) normal delivery (e) stillbirth (b) spontaneous abortion (f) birth defects (c) induced abortion (g) premature birth (d) ectopic pregnancy (h) caesarean section 3. Have you made any previous partner pregnant? If yes, please give dates (a-d) and note any adverse outcome (e-h): (a) normal delivery (e) stillbirth (b) spontaneous abortion (f) birth defects (c) induced abortion (g) premature birth (d) ectopic pregnancy (h) caesarean section 4. Has your current partner had any pregnancies previously with someone other than you? If yes, please give dates (a-d) and note any adverse outcome (e-h): (a) normal delivery (e) stillbirth (b) spontaneous abortion (f) birth defects (c) induced abortion (g) premature birth (d) ectopic pregnancy (h) caesarean section 1.
2 5. For how many months have you used any of the following contraception methods? (Please give dates, if possible) Condom: Diaphragm: Foam: IUD: Pills: Rhythm: 6. Have you ever undergone sterilization (e.g.,vasectomy)? 7. Has your partner ever undergone sterilization (e.g.,tubal ligation)? 8. Have you been examined for infertility problems elsewhere (please list MD)? 9. Have you received treatment for infertility problems elsewhere? C. Sexual History: 1. Rate your level of sexual desire: marked moderate slight none 2. How many times each week do you have sexual intercourse? 3. How many times each week do you masterbate? 4. Do you ejaculate during sexual intercourse? 5. Do you ejaculate into your partners vagina? 6. Does semen leak out of your partners vagina after intercourse? 7. Do you ever ejaculate prior to penetration for intercourse? 8. How many minutes does intercourse last before you ejaculate? 9. Do you obtain an erection easily? 10. Do you often have erections in the morning? 11. Are you aware of erections in the night? 12. Have you ever ejaculated through a flaccid (soft) penis? 13. Do you often ejaculate prior to penetration for intercourse? 14. Is intercouse ever painful to you? 15. Is intercourse painful for your partner? 16. Is your partners vagina so tight that you cannot penetrate? 17. Do you use any form of lubrication for intercourse? if so, what type 18. Rate you partners level of sexual desire: marked ;moderate ;slight ;none 19. Are your partners menstrual periods regular? 20. Do you have intercourse every other day during expected ovulation? 21. Is your partner subject to vaginal infections? 22. Has your partner ever had any of the following illnesses? If so, please note date and treatment: Herpes simplex (Type I or II): Pelvic inflammatory disease (PID): Venereal disease (VD): Gonorrhea (GC): Non-specific urethritis (NSU): Syphilis: 23. Has your partner had abdominal surgery? 24. Does your partner douche immediately following intercourse? 25. Does your partner usually get out of bed shortly following intercourse? YES NO 26. Have you ever had same sex intercourse (anal or oral)? 27. Have you engaged in sex for pay within the past 5 years? 28. Has any prior partner tested positive for the HIV (human immunodeficiency virus)? D. General Medical History: 1. Have you ever had any of the following illnesses or conditions: Allergies (please list) 2.
3 YES NO Arthritis (or other autoimmune disease) Bowel disorders Cancer (Please describe): Change in body appearance Change in facial appearance Color blindness Deafness Diabetes Heart problems Hepatitis Type: HIV infection (AIDS) Liver Disease Lung or breathing problems Thyroid disease Generalized viral infection (i.e.,mono,encephalitis) Nervous system disease (e.g.,creutzfeldt-jacob, Multiple Sclerosis, Alzheimer's, encephalitis) Sickle cell disease Smallpox Influenza Tuberculosis Ulcers Frequent episodes of indigestion or abdominal pain Neck or back problems Skin diseases High blood pressure Receipt of Pituitary Growth Hormone Date of last treatment: Blood transfusions Date of last treatment: Received Blood components (e.g, factor VIII,IX or others) Date of last treatment: E. Urological History: 1. Have you ever had infection of the: prostate epididymis testicles 2. Have you ever had kidney stones? 3. Have you had: venereal disease (VD) non-specific urethritis (NSU) Gonorrhea (GC) Syphillis Date of last treatment: Herpes simplex (Type I or II) 4. Have you ever had a clear, white, yellow or green discharge from the tip of your penis? 5. Have you ever had a urinary tract infection (UTI)? 6. Have you had a fever in the past three months? 7. Have you ever had blood in your semen (ejaculate)? 8. Have you ever had pain in your scrotum or testicles? 9. Were either of your testicles undescended at birth? 10. Have you ever had any injury to your testicles or penis? 11. Have you ever had mumps? if yes, did it affect your testicles: 12. Have you ever had an operation for (please give dates): Hernia Varicocele (varicose veins in the scrotum) Hydrocele Undescended testis 3.
4 Any abdominal surgery Operation on the testis Vasectomy Circumcision or other surgery on the penis Other surgery (please list with dates) Have you ever had a blood transfusion (Date) F. Endocrine History: 1. Do you have or have you ever had: YES NO Difficulty smelling Headaches (persistent or recurrent) Visual problems Enlarging hands or feet Problems with perspiration/sweating Changing skin color Frequent episodes of lightheadedness or dizziness Growth problems Do you have a general sense of well being Do you notice a recent change in your energy level Do you have wide mood swings 2. At what age did you first: note armpit hair pubic hair shave 3. How often do you shave: once a day twice a day once a week twice a week or less 4. Is their any change in the texture or quantity of body hair? 5. How does your beard compare with other men in your family: same sparser heavier G. Occupational History: 1. What is your present occupation? 2. Past occupations? 3. Is your occupation stressful? 4. Do you need to meet rigid deadlines or time schedules? 5. Do you frequently travel? 6. Do you fall asleep easily? 7. Do you wake up early? 8. In your work or at any other times, have you been exposed to any of the following: Prolonged heat Radiation Pesticides Agent orange Industrial solvents Dyes Heavy metals (e.g., lead, mercury, gold) Plastics 4.
5 YES NO H. Medications and Drugs: 1. Are you taking or have you taken any of the following medications: Allopurinol Antidepressant drugs Antihistamines Antihypertensive drugs Antiparasite agents Anti psychotic agents Aspirin Barbituates Chemotherapy for cancer Cholestyramine Clofibrate Digitalis Dilantin Diuretics Hormones (estrogen,testosterone,thyroid,cortisone) Immunosuppresant drugs Insulin Nicotinic acid Norpace Penicillin Streptomycin Sulfa drugs Tagamet (Cimetadine) Tetracycline Tranquilizers 2. Please list all medications you are currently taking (please include dosage and frequency): I. Social History: 1. Do you smoke? b.if yes, how many cigarettes do you smoke each day? 2. Do you consume alcoholic beverages (if yes, how often)? 3. How many cups of coffee or caffeine-containing beverages do you drink each day? 4. Have you ever been an inmate in a correctional facility When Duration 5. Do you use any of the following substances: Amphetamines Quaaludes Marijuana Cocaine LSD Angel dust Heroin Methadone Any nontherapeutic injected drug use Date of last use: 6. Do you often take long hot baths? 7. Do you have any tattoos or skin piercings? When Where 8. Have you beeen bitten from an animal suspected of having rabies? When 5.
6 J. Family History: YES NO 1. Was your mother ever given diethylstilbesterol (DES)? 2. How many sisters do you have? Please give the number of children of each of your sisters: sister #1 sister #2 sister #3 sister #4 3. How many brothers do you have? Please give the number of children of each of your brothers: brother #1 brother #2 brother #3 brother #4 4 Are any of the following diseases or conditions present in your family? birth defects Bowel disorders Cancer Cystic Fibrosis Diabetes Extra Fingers or Toes Heart Disease High blood pressure Hormone problems Kidney disease Lung disease Poor sense of smell Tuberculosis Ulcers Any known genetic disease Tay-Sachs disease Thalassemia (alpha or beta types) Cystic fibrosis Sicle cell disease 5. Have either you or any family member had any of the following(if so, please note relation and type[if known]) Congenital (present at birth) malformations: Please describe: Genetic diseases or disorders: Please describe: H. Partner History: 1. Has your partner been seen by a fertility specialist? (if so, please list and give dates)? Please describe: 2. Has your partner had any of the following tests/procedures? (if so, please note date and result [if known]) Basal body temperature (BBT): Results:: Blood tests (FSH,LH, estradiol): Results:: Post coital test (PCT): Results:: Hysterosalpingography (HSG): Results:: Endometrial biopsy: Results:: Laparoscopy: Results:: IUI or IVF cycles: Results:: 3. Does your partner have any allergies (including any medication or food allergies)? If so please list each and describe reaction. Please describe: 6.
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Bruce R. Gilbert, M.D., Ph.D. Director, Reproductive and Sexual Medicine Smith Institute For Urology North Shore - Long Island Jewish Health System Date: GENERAL UROLOGY QUESTIONNAIRE Please fill out the
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Christine Chai, M.D. 901 Dover Drive, Suite 214 Newport Beach, CA 92660
Christine Chai, M.D. 901 Dover Drive, Suite 214 Newport Beach, CA 92660 Patient Information: Birth Date: Age: Last Name: First: Middle: Address: City: Zip Code: Telephone#: Cell Phone#: Social Security
J. Van Lier Ribbink, M.D., F.A.C.S. Center for Endocrine and Pancreas Surgery at Honor Health
J. Van Lier Ribbink, M.D., F.A.C.S. Center for Endocrine and Pancreas Surgery at Honor Health Patient Clinical Information Questionnaire 1.0 Date of Questionnaire Completion; / / 2.0 Patient Data 2.1 Name:
Name: Date of Birth: Age: Address: City State Zip
Today s Date: Client History Name: Date of Birth: Age: Address: City State Zip Cell Phone: Home Phone: Work Phone: Email Address: Female Male Emergency Contact: Phone Number: How did you hear about us?
STI Review. CALM: STI/HIV - Lesson One (Handout 3) Bacteria/ Transmission. Symptoms. Disease. Virus
STI Review Bacteria/ Virus? Transmission Chlamydia Bacteria Unprotected vaginal or anal sex with a person who has Chlamydia Genital Herpes Virus By direct contact with the sores or blisters of an infected
City State Zip Code. Ethnic Background: Caucasian African-American Asian Hispanic Native American. Previous. Hobbies/Leisure activities:,,,
History # UPIN # (Please leave blank) Name: First M.I. Last Address: Street (Apt #) City State Zip Code Phone number: ( ) ( ) Home Business Birth Date: / / Day-Month-Year Gender: M F Marital status: (Maiden
How did you hear about us?
How did you hear about us? (please c all that apply) Physician referral Newspaper or Magazine Ad Radio Ad TV Ad Web Ad Web Search In the News please circle: print / TV / radio / online Friend or Family
MONTEFIORE MEDICAL CENTER TRANSPLANT PROGRAM LIVING DONOR EVALUATION FORM History Questionnaire
MONTEFIORE MEDICAL CENTER TRANSPLANT PROGRAM LIVING DONOR EVALUATION FORM History Questionnaire Donor s Name: Today s Date: Social Security #: Date of Birth Age Sex Address: Telephone #: (home) (work)
Patient History Form
Patient Personal Information Name: Date: Age: Occupation: Employer's name: Briefly describe your daily activities at work: Sex: male female Marital Status: single married divorced widowed Spouse's name:
THERMOGRAPHY CLINIC 1596 REGENT ST. SUDBURY, ON P3E 3Z6
THERMOGRAPHY CLINIC 1596 REGENT ST. SUDBURY, ON P3E 3Z6 HEALTH HISTORY Name: Age: Date of Birth: Address: City: Postal Code Home Tel: Work Tel: E-mail Occupation: Marital Status: S M D W SEP. Number of
MYTHS OF STIs True or False
MYTHS OF STIs True or False 1. Most people with an STD experience painful symptoms. 2. Birth control pills prevent the spread of STDs. 3. Douching will cure and STD. 4. Abstinence is the best way to prevent
1. What is your date of birth? Month Day Year
Participant ID # Today's Date 1. What is your date of birth? Month Day Year 2. How would you describe your race / ethnicity? African American / Black European American / White Hispanic Asian Native American
Name : Date of Birth : Social Security #: Age: Address: City: State: Zip Code: Home Phone: Work Phone: Cell Phone: Address: May we leave a
Name : Date of Birth : Social Security #: Age: Address: City: State: Zip Code: Home Phone: Work Phone: Cell Phone: Email Address: May we leave a message? Home Work Cell PLEASE DO NOT LEAVE A MESSAGE Marital
How is it transferred?
STI s What is a STI? It is a contagious infection that is transferred from one person to another through sexual intercourse or other sexually- related behaviors. How is it transferred? The organisms live