140 Charlois Blvd Winston-Salem, NC 27103 P 336.716.4131 / f 336.716.9042 Director Ryan Terlecki, MD, FACS www.wakeforestmenshealth.com
Male Fertility Questionnaire
Name:
Address:
Phone (home):
Phone (cell):
Email:
Date of Birth:
Relationship Status: o Single o Married o Divorced o Separated o Widowed
Partner Name (if applicable):
Partner contact (phone/email): Only complete the following questions if you HAVE NOT HAD A VASECTOMY:
For how many months have you been trying to achieve pregnancy with your current partner?
Age of current partner:
Have you ever been involved with a prior pregnancy with your current partner? (Yes/No) :
If so, please provide date/outcome of each:
Have you ever been involved with a prior pregnancy with a different partner? (Yes/No) :
If so, please provide date/outcome of each:
Has your partner ever achieved pregnancy with someone else? (Yes/No) :
If so, please provide date/outcome of each:
Have you used any of the following forms of contraception? (Yes/No):
o condoms o diaphragm o vaginal foam o IUD o oral contraceptives o rhythm method
Have you had a prior semen analysis? (Yes/No):
If so, was the analysis abnormal? (Yes/No):
If so, check all that apply: o no sperm o low sperm count o poor motility o poor morphology
How many times per week do you achieve ejaculation within your partner’s vagina?
140 Charlois Blvd Winston-Salem, NC 27103 P 336.716.4131 / f 336.716.9042 Director Ryan Terlecki, MD, FACS www.wakeforestmenshealth.com
Do you use any products for lubrication during sexual activity?
Has your partner ever had a sexual infection? Select appropriate box(es): o None o Herpes o Chlamydia o Gonorrhea o Syphilis o Pelvic inflammatory disease
Have you ever had a sexual infection? Select appropriate box(es): o None o Herpes o Chlamydia o Gonorrhea o Syphilis o Pelvic inflammatory disease
Any childhood infection with mumps? (Yes/No):
Any history of genital trauma? (Yes/No):
If so, please explain:
Any history of genital surgery (other than infant circumcision)? (Yes/No) :
If so, please explain:
Were you born full term? (Yes/No):
Were both testicles descended at birth? (Yes/No):
Do you feel the milestones of puberty occurred at the normal time or later than your peers? (Examples:
Voice change, facial/body hair appearance): o Normal o Late
Occupation:
Does your occupation expose you to any hazardous chemicals, radiation, or intense heat for prolonged periods of time? (Yes/No):
If so, please explain:
Have you ever taken any hormonal therapies, antidepressant medications, or men’s health supplements? (Yes/No):
If so, please explain:
Do you currently or have you ever used tobacco products? (Yes/No):
Do you currently or have you ever used marijuana? (Yes/No):
Do you currently or have you ever used illegal drugs other than marijuana? (Yes/No):
In a typical week, how many alcoholic beverages will you consume?
Do you have any family history of infertility or birth defects? (Yes/No):
If so, please explain: