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: .