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?