140 Charlois Blvd Winston-Salem, NC 27103 P 336.716.4131 / f 336.716.9042 Director Ryan Terlecki, MD, FACS www.wakeforestmenshealth.com

Male 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 :

For how many months have you been trying to achieve 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 o diaphragm o vaginal foam o IUD o oral contraceptives o rhythm method

Have you had a prior 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 ? Select appropriate box(es): o None o Herpes o o 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 )? (Yes/No) :

If so, please explain:

Were you born full term? (Yes/No):

Were both 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 or birth defects? (Yes/No):

If so, please explain: