Duration of Infertility yrs/months
Nature of present employment
Concerns regarding chemical exposure at your current employment?
Military history? NoYes
If so, when
Have you gained or lost greater than 20 pounds in this past year? YesNo
If yes, please specify
Do you use any dietary aids? YesNo
Weight loss products? YesNo
If yes, please specify amount
Do you or have you ever used:
if yes, how much per week do you consume?
if yes, amount per day
if yes, please specify
Do you currently exercise?
What form of exercise?
How many hours per week?
Do you use saunas, steam baths or hot tubs?
Do you or have you in the past used anabolic steroids?
If yes, when
Please list any allergies to medications, food, Iodine:
High blood pressure
Condyloma (genital warts)
Have you ever had surgery for vasectomy reversal?
If yes, when?
Have you ever had a varicocele repair?
Have you ever had hernia repair?
Please list any other surgeries and dates
Are you circumcised?YesNo
Are you aware of any scrotal abnormalities as a young child?
At -what age did you begin to shave regularly or grow facial hair?
How many times have you been married?
Have you ever produced a child with another partner?
If yes, how long did it take to conceive?
Do you have any trouble getting an erection?YesNo
Maintaining an erection?YesNo
Any concerns regarding premature ejaculations?YesNo
How many times per week do you and your spouse/partner have sexual intercourse?
How many times around ovulation do you and your spouse/partner have intercourse?
Do you and your spouse/partner use lubricants? If yes, which ones do you use?
List any medications mat you have taken for infertility and approximate dates used:
What prior testing/treatments if any, have you had for infertility?
Please provide other information you feel is pertinent and not included in this fertility questionnaire.
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