Male Fertility Questionnaire

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1 Male Fertility Questionnaire Name (Last, First) Age Date Birth Date / / Address: City: State: Zip: Phone(cell) address: How did you hear about Presidio Acupuncture? Friend (who?) Internet MD/Midwife Other Emergency Contact: Relation: Phone #: Regular Medical Doctor: Fertility Specialist / Clinic: Start Date: Mo/Yr Occupation: Employer: General Questions Have you ever had acupuncture before? Y N Do you have a pacemaker, heart arrhythmia, or other heart condition? Y N Have you ever had blood-clotting problems or problems with bleeding? Y N Are you on blood thinning medications? Y N Do you take aspirin regularly? Y N Have you ever been diagnosed with Hepatitis? HIV? AIDS? TB? Y N If so, when? Surgical History: Please list all surgeries and approximate age:

2 Hospitalizations and approximate date: Specific allergies and reaction: Major Accidents/Injuries (include head injuries, fractures, deep cuts, serious sprains, etc.) Indicate date or age: Were there any abnormal or memorable conditions surrounding your birth: Family Medical History (any medical conditions that run in your family) Diabetes Cancer High Blood Pressure Heart Disease Stroke Depression/Mental Illness Alcoholism/Drugs Other Medication History List all medications and supplements you are currently taking: Western Diagnosis 1. Results for Semen Analysis: Date Count Morphology Motility Volume

3 Date Count Morphology Motility Volume 2. Do we have a copy of your Semen Analysis? Y / N 3. Please list the date if you have had any of the following procedures: Varicocele Vasectomy Vasectomy Reversal SCSA/ASA Other: 4. Plans for ART: IUI Clomid IVF PGD Donor Egg Surrogate Other 5. Have you fathered children Y / N If so, how many 6. Please circle all that apply to your PAST medical history: Infection Chlamydia Erectile Dysfunction Ejaculation Problems Retrograde Ejaculation Prostate Cancer BPH Anti-sperm Antibodies Sperm Chromatid /DNA Integrity High Cholesterol Diabetes Other 7. Please circle all that apply to your CURRENT medical condition: Infection Chlamydia Erectile Dysfunction Ejaculation Problems Retrograde Ejaculation Prostate Cancer BPH Anti-sperm Antibodies Sperm Chromatid /DNA Integrity High Cholesterol Diabetes Other 8. Spouse s Name 9. Western Diagnosis of Spouse Pain PAIN: please indicate on the figures below the areas of the body you experience pain:

4 How would you characterize your pain (circle all that apply): dull/achy sharp/stabbing burning tingling numbness electrical superficial deep shooting The pain is (circle all that apply): better/worse with heat better/worse with cold better/worse with pressure better/worse with movement better/worse with rest worse in am/pm Exercise, Diet & Energy: On a scale of 1-10 please rate your energy level. What time of day is your energy: Highest? Lowest? Do you fatigue easily? Please list some of your favorite foods: Circle all the foods/flavors you enjoy and eat often: spicy sweet salty bitter fresh/raw foods fried food dairy canned foods frozen foods/microwave meals fast food sodas coffee red meat white meat How often do you exercise? What kind of exercise do you do? Do you sweat when active? Sweat when inactive? Night sweats? Height Weight Weight 1 year ago Highest Weight

5 Emotions & Sleep: Do you have (circle all that apply): panic/anxiety attacks bad/short temper nervousness sadness crying spells tendency to worry poor memory difficult concentration Briefly describe a typical night of sleep for you. How long do you normally sleep? hours per night Do you take naps? How often? I have difficulties with (circle all that apply): falling asleep staying asleep dream-disturbed sleep Do you often experience waking up and not being able to fall asleep again? No Yes, usually at am/pm Number of times per night you get up to use the restroom On a scale of 1-10 please rate your stress level How do you relax? How do you feel about your work? Are you in a relationship? How do you feel about your relationship? What is your most predominant emotion? Please check the box next to any conditions that apply to you, past and/or present Head and Face Heart and Chest Skin Headaches High Blood Pressure Acne Dizziness Low Blood Pressure Dryness Memory Loss Chest Pain Moles that Change Other Chest Tightness Lumps Difficulty Lying Down Excessive Sweating Eyes Other Night Sweats Blurry Vision Rarely Sweat Eyelid Twitching Circulation Other Floaters Easy Bruising Pain Easy Bleeding Neurological Cold Limbs-Hands or Feet Nervousness/Anxiety Nose Body Temp Runs Cold Numbness or Tingling Tremors Body Temp Runs Hot Lack of Coordination Frequent Colds Nerve Pain Sinus Trouble Gastrointestinal Bleeding Always Thirsty Never Thirsty Mouth Excessive Appetite Dental Problems Low Appetite Gum Problems Gas/Bloating Teeth Grinding/TMJ Stomach or Abdominal Pain Unusual Tastes Nausea Other Diarrhea/Loose Stools Constipation Throat Rectal Bleeding Sore Throat Colon Problems Hoarseness Difficulty Swallowing Urination Dryness Frequent Other Difficult Informed Consent

6 I,, hereby authorize the licensed acupuncturist at Mama Lounge to administer any style of Chinese Medicine relevant to my diagnosis and treatment, including but not limited to the following: Insertion of disposable, stainless steel acupuncture needles of various sizes into my body at different depths and locations. Heated moxibustion treatment using the herb Artemisia vulgaris, or a heat lamp may be placed on or near any part of my body. There is also indirect moxibustion treatment where the herb may be placed on the head of a needle or on ginger or salt which rests on the skin. The heat might cause slight discomfort or leave a small scar or blister on the skin. With any type of heat, there is risk of burn. A vigorous massage technique called gua sha may produce redness, tenderness or slight bruising of the skin that will last from 1-5 days. Cupping may be used to promote circulation. Suction from the cups may produce red or purple spots that can last 1-5 days. Electrical Stimulation may be used to enhance the treatment at various acupuncture points. I have been informed that I have the right to refuse any form of treatment. I understand the nature of the treatment, have been informed of the risks and possible consequences involved with this treatment, and was given an opportunity to ask questions pertaining to my treatment. I also understand there is always the possibility of unexpected complications and I understand that no guarantee can be made concerning the results of treatment. Patient Signature: Print Name: Date: Before Treatments Bring a list of all medications and supplements you are taking DO NOT wear perfumes or any other strong scents Be prepared to undress down to your undergarments Do not drink coffee the day of your visit Have a light meal or snack before visit. A full stomach or empty stomach could cause nausea or dizziness Drink plenty of water day of treatment Do not eat or drink anything that changes the color of your tongue and try not to brush your tongue Do not have any alcohol or drugs in your system from the night before After Treatments Do not drink alcohol Do not eat greasy, spicy, or cold foods Do not exercise Spend the rest of the day relaxing! Patient Signature: Print Name: Date: THANK YOU FOR YOUR COOPERATION IN THOROUGHLY COMPLETING THIS FORM