Male Fertility Questionnaire 1. What is your first name? 2. What is your surname? 3. What is your age? 4. What is your date of birth (dd/mm/yyyy)? 5. What is your address? 6. Can post be sent to this address? 7. What is your country of birth? 8. What is your occupation? 9. What is your home telephone number? 10. What is your mobile telephone number? 11. What is your contact number at work? (for emergency use only) 12. May we have permission to leave voice messages on your contact numbers (excluding work number)? 13. What is your email address? 14. May we have permission to send out documents and/or information by email to the address supplied above? 15. Doctor's Name: 16. Practice Name: 17. Address: 18. Do we have permission to contact your G.P.? 19. Are you currently in a relationship? 20. If yes, how many years are you together? 21. Duration of time trying to conceive with current partner (if applicable)? 22. No. of years of unprotected intercourse (with all partners)? 23. Have you had any pregnancies with a previous partner? If yes, please give details below. 24. Have you had previous semen analysis carried out? If yes, please indicate when and where and if the result was normal/abnormal in the box below. 25. Do you have problems producing semen samples by masturbation? 26. Have you ever suffered from any of the following? Mumps- affecting testesUndescended testesMajor trauma to testesTesticular torsion (twist)Varicocoele repairHernia repair 27. Have you ever had any of the following? Difficulty achieving an erectionDifficulty maintaining an erectionDifficulty with premature ejaculation (i.e. ejaculating before penetration)Pain with ejaculationBlood in your ejaculationOther 28. Have you ever had a sexually transmitted infection? YesNo 29. Please indicate any operations/procedures you have had that may have an affect on fertility, e.g.varicocoele, orchidopexy (for undescended testes). 30. Please list any past or current serious illness(es) 31. If you are currently taking any medications, please give details below 32. Do you have any allergies? If yes, please give details below 33. Is there a family history of inherited diseases? If yes, please specify below. 34. What is your weight without your clothes? 35. What is your height, without shoes? 36. Have you ever taken anabolic steroids? 37. How many hours per week do you work? 38. How many hours do you sleep, on average, per night? 39. How often do you exercise per week? 40. What type of exercise do you do? 41. Do you smoke cigarettes? 42. If yes, how many cigarettes do you smoke per day? 43. Do you drink alcohol? 44. If yes, how many units of alcohol do you drink per week? 45. Do you take recreational drugs (e.g. marijuana, cocaine etc)? 46. If yes, please specify what drug and how often: 47. Have you ever suffered from depression or high levels of anxiety? 48. Have you ever received treatment from a psychiatrist/ mental health team or been admitted for a psychological issue? 49. Have you ever been affected by violence in your life (physical, mental, emotional or sexual)? 50. Do you have relationship concerns (e.g. partner, parents, family) you wish to discuss? 51. Are you under stress in work or in other areas of your life? 52. Do you experience any sexual difficulties including lack of desire? 53. Have you ever been on or, are currently on, antidepressants, mood stabilisers or anti-psychotic medication? 54. Do you struggle to cope with your (or your partner's) fertility problems? 55. In the last few months have you felt down, depressed or hopeless? 56. If you have answered yes to any of the above, would you like someone to help you with these issues? 57. Please enter today's date (dd/mm/yyyy) I confirm that the information I have provided to My Fertility Check on this form is true and accurate
