Fertility Questionnaire – Male


CLIENT INFORMATION

Your Name         

Partner's Name

Address             

Mobile Phone     

E-mail address  

Skype name  

Date of birth       

Partner date of birth


Please fill in form, tick boxes and add comments if applicable

What is your occupation? Please be specific, list activities

How long have you been trying to conceive?

Cause of infertility (if known)

Does your partner have any fertility issues? If so, please describe

Are you taking any prescription medication?

Are you taking any supplements (vitamins, minerals, etc.), herbs, homeopathic medicines, etc.?

Have you/or your partner been taking any recreational drugs within the last 2 years? If so, please describe

Do you have a history of any of the following infections?
Herpes Chlamydia Venereal Warts Gonorrhea Other


GENERAL HEALTH

Describe your overall state of health.

Do you consider yourself:
Not very healthyhealthyperfectly healthy

Height: Weight:
Current health problems not related to infertility

How do you rate your energy levels? lowmediumhigh

How often in the last year have you suffered from infections, colds, flu, etc?
Neveroccasionallyfrequently

Have you taken any of these medications within the last 5 years?

Antibiotics - If so, when
Antidepressants - If so, when
Steroid based medication - If so, when
Antihistamines - If so, when or how often
Panadol or other pain medication - If so, when or how often
Other

Environment
Do you use pesticides/herbicides? YesNo
Do you use insect repellent? YesNo
Have you been exposed to chemicals? YesNo
Do you use chemicals on a regular basis, ie. work? YesNo
In the past 2 years have any activities involved frequent contact with chemicals including plastics, paints, new carpets, new car, glues, insecticides, hair chemicals, pest control, etc.? YesNo
If yes, give details

Do you fly frequently? YesNo
Do you have electrical appliances in your bedroom? YesNo
If yes, give details

Hobbies and other activities (please include gardening, sports activities, crafts, etc)

Do you experience any of the following? Please tick the appropriate box.

AcidityHay fever
AcneHeadaches
AnemiaHerpes
Anorexia/BulimiaHigh/low blood sugar
AnxietyHigh blood pressure
ArthritisInsomnia
AsthmaIrritable bowel syndrome
Autoimmune diseaseJoint/muscle pain
Bleeding gumsKidney problems(kidney stones, fluid retention)
BloatingLeukemia
Blood Pressure(high/low)Liver issues
Bone SpursMigraine
Bowel ProblemsMouth ulcers
Brittle nailsNasal/sinus congestion
Burping, RefluxNausea (during period or random?)
Cancer or Tumours:Nervousness
CandidaNumbness/tingling
Cholesterol issuesPalpitations
Chronic fatigueRespiratory problems
Cold hands/feetSciatica
Colic (Flatulence, wind)Skin conditions (eczema, psoriasis, etc.)
ConstipationSleepiness/Tiredness
DandruffSweats (excessive)
DepressionTeethproblems
DiabetesThrombosis
DiarrheaThrush
Digestive ProblemsThyroid problems
EpilepsyUrinary tract infections
Eye Problems (Conjunctivits, styes)Varicose veins
Food or seasonal allergies/hay feverVertigo (Dizziness)
Fungal conditionsWarts
Gall Bladder problemsWeight problems
Glandular Fever (now or in the past)Worms
GoutVaccinations within the last 5 years
HairlossOther

Lifestyle/Diet

I drink alcohol I smoke
I regularly drink soft drinks/diet drinks I drink water from the tap (unfiltered)
I drink coffee/tea I microwave my food
I use perfumes/deodorants/antiperspirants I drink less than 8 glasses of water a day
I have take away food more than once per week I have a lot of stress in my life (ie. work, home,)
I crave carbohydrates I crave salty food
I get heartburn/reflux I am vegetarian/vegan
I have strong cravings for (ie. chocolate, sugar, etc.)

Do you have any erection issues?

Do you have any ejaculation issues?

Is you hair falling out? (if yes, have you ever used medication for this?

Do you have prostate problems?

Do you have sperm issues?

Do you have testicular problems? (varicocele, pain, etc.)

Anything else you think I should know? Any other past health issues?