The ART Institute of Washington, Inc. at MALE PATIENT HISTORY

The ART Institute of Washington, Inc. at
Walter Reed Army Medical Center
MALE PATIENT HISTORY
Date Completed
I. PATIENT INFORMATION
Name
Partner's Name
Date of Birth
Partner's Date of Birth
Phone Number Day
Phone Number Evening
Address
City
Current Occupation
Email Address
State
Zip Code
Il. GENERAL MEDICAL HISTORY
Height (inches)
Weight (lbs)
Do you follow a particular food diet or have special dietary habits
Do you exercise regularly
Yes
Yes
Have you lost >20 lbs this year
No
Yes
No
Primary Exercise
Have you ever had surgery of the pelvis, scrotum, testicles
No
Hours/Week
Yes
No
Specify Date/Type of Surgery
Do you have or have you ever had (check all that apply):
Anemia
Appendicitis
Arthritis
Blood Transfusion
Breast Discharge
Breast Soreness
Cancer (see below)*
Chlamydia
Chronic Bonchitis
Colitis
Cystic Fibrosis
Diabetes
Dizziness
Epilepsy
Gallbladder Problems
Gonorrhea
Heart Disease
Hepatitis
Herpes
Mumps
High blood pressure
Kidney infection
Kidney Stone
Liver Problems
Loss of Balance
Vasectomy
Neurological Problems
Urethritis
Prostatitis
Testes Infection
Testes Trauma
Pneumonia
Poor sense of smell
Rheumatic fever
Scarlet Fever
Seizures
Syphilis
Thyroid problem
Tuberculosis
Ulcers
Testes Surgery
Varicocele
Visual Disturbance
Other medical problem**
*Type of Cancer, diagnosis and treatment dates
Have you ever received chemotherapy
Yes
No
Have you ever received radiation therapy
Yes
No
**Other medical problem (list)
Do you frequently take saunas or steam baths
No
Yes
Have you had a high fever (>102F) in the past 3-4 months
Yes
No
Are you taking any prescription or over-the-counter medications
Yes
No
List All Medications
Do you have any allergies (medication, latex, food)
Yes
No
List Allergies (and reaction)
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This form is not to be used or reproduced without the expressed written consent of the ART Institute of Washington, Inc.
Do you use or have you ever used (check all that apply):
Alcohol
Yes
No How many glasses/Drinks per week
Tobacco
Yes
No Number of packs per day
Illicit or Recreational drugs
No
Yes
Years of tobacco use
If you would be more comfortable not writing
anything down, please discuss this directly with
your physician.
Explain
III. EXPOSURE HISTORY
Are you or have you ever been exposed to any of the following during employment or military service (check all that apply):
Heat
Chemicals
Toxic Fumes
Nuclear Radiation
Other Specify
Do you currently or have you ever used workout supplements
other than vitamins (steroids, DHEA-S, androstendione, creatine,
prohormones, etc). Specify and note dates of use.
IV. REPRODUCTIVE/SEXUAL HISTORY
How long have you and your partner been trying to get pregnant
How many times per week do you have sexual intercourse
How many times do you have intercourse around her ovulation
Are you circumcised
Yes
No
When you were born, were both testes descended in the scrotum
Have you ever fathered a child
Yes
No
Yes
No
How many children
No
Yes
Do you have trouble getting or keeping an erection
Do you have trouble with ejaculating (premature, retrograde, unable)
Have you noticed a decreased in sexual drive
Yes
No
Yes
Do you ever have orgasms with masterbation without ejaculation
No
Yes
Do you have any discharge from the penis
No
Yes
No
At what age did you start shaving regularly or start to grow a beard
Have you ever had a varicocele repair
Yes
No
Have you ever had a vasectomy reversal or repair
Yes
Have you ever had a surgical retrieval of sperm (MESA, TESE)
Have you ever been treated for infertility before
Yes
No
No
Yes
No
What cause of infertility was diagnosed
Have you and your partner undergone Intrauterine Insemination (IUI)
Have you and your partner undergone In-Vitro Fertilization (IVF)
Is your partner seeing a physician for female infertility
Yes
Yes
Yes
No
No
Total Number of IUIs
Total Number of IVF Cycles
No
What is your partner's infertility diagnosis
Has your partner had a child with another man
Yes
No
This form is not to be used or reproduced without the expressed written consent of the ART Institute of Washington, Inc.
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Which of the following tests have you had performed? Check all that apply and the results/dates if known:
Hormone Assay (FSH, LH, progesterone, estrogen)
Androgen levels (testosterone, DHEA-S)
Glucose/insulin
Chromosome/Karyotype
Semen Analysis
Ultrasound of the scrotum
Thyroid function
Testicular Biopsy
Hamster egg test
Chlamydia test
Other
What drugs have you taken for infertility? Check all that apply:
Clomiphene Citrate (clomid)
hMG (pergonal, menopur)
Tamoxifen
Testalactone
GnRH (lupron)
hCG (ovidrel)
FSH (gonal-F, bravelle)
Danazol (danocrine)
Bromocriptine (parlodel)
Steroids (prednisone, dexamethasone)
Letrozole
Other
V. FAMILY HISTORY
Is there a family history of infertility
Yes
Is there a family history of hormonal disorders
No
Yes
Specify
No
Specify
VI. ADDITIONAL INFORMATION
Please provide any additional information or use this space to elaborate on any of the above questions.
Print Form
This form is not to be used or reproduced without the expressed written consent of the ART Institute of Washington, Inc.
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