Consistently above the national birth rate average in all measured categories*
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Call Us: (636) 330-1126
Call Us: (636) 330-1126
Home
Fertility 101
Your First Visit: What to Expect
Women’s Infertility
Men’s Infertility
Secondary Infertility
New Patients
Treatments
Success
Blog
Request A Consultation
Patient Registration (Male)
Have you been evaluated by a urologist?
Yes
No
Have you previously conceived with another woman?
Yes
No, but we were using birth control
No, and we were not using birth control
How many times have you previously conceived?
Please enter a number greater than or equal to
0
.
Have you had a semen analysis?
Yes
No
Do you have difficulty with erections?
Yes
No
Do you have retrograde ejaculation of sperm into the bladder?
Yes
No
Have you had any of the following STIs or pelvic infections?
Chalmydia
Gonorrhea
Herpes
Genital warts or HPV
Syphilis
HIV/AIDS
Hepatitis
Other
Have you had a history of undescended testicles?
Yes
No
Do you have scrotal or testicular pain?
Yes
No
Did you have mumps after puberty?
Yes
No
Have you had any prior injury to your testicles that required surgery?
Yes
No
Have you been diagnosed with any of the following diseases?
Diabetes Mellitus
Multiple Sclerosis
Prostatic Infection
Urinary Infection
Cancer
Other neurologic problem
Have you had a fever within the last 3 months?
Yes
No
Have you had a vasectomy?
Yes
No
Have you had a vasectomy reversal?
Yes
No
Have you had surgery for varicocele repair?
Yes
No
Did you undergo any bladder or penis surgery as a child?
Yes
No
In your workplace, are you exposed to heat for prolonged periods of time?
Yes
No
Have you undergone chemotherapy?
Yes
No
Are you allergic to any medications?
Please list each medication you are allergic to and the symptoms of your reactions.
List any current medications that you take.
List any current medical problems you have.
How many caffeinated beverages do you drink per day?
Please enter a number greater than or equal to
0
.
Coffee, soda, tea, energy drinks, etc.
How many cigarettes do you smoke per day?
Please enter a number greater than or equal to
0
.
How many cigarettes do you smoke per day?
Please enter a number greater than or equal to
0
.
How many drinks do you have per day?
Please enter a number greater than or equal to
0
.
A drink is 12 oz of beer, 5 oz of wine, or 1.5 oz of hard liquor.
Do you use recreational drugs?
Do you take any herbal medicines or supplements?
Have you been exposed to any toxic or radioactive materials?
Not including routine x-rays.
Do you use hot tubs regularly?
Yes
No
Were you exposed to DES while in utero?
Yes
No
Diethylstilbestrol (DES), also known as stilbestrol or stilboestrol, is an estrogen medication which is mostly no longer used.
Has anyone in your immediate family had difficulty conceiving a child?
Does your family have a history of any of these medical conditions?
Cystic Fibrosis
Tay-Sachs Disease
Canavan Disease
Bloom Syndrome
Gaucher Disease
Niemann-Pick Disease
Fanconi Anemia
Muscular Dystrophy
Neurologic (brain/spine)
Neural Tube Defects
Bone/Skeletal Defects
Dwarfism
Developmental Delay
Learning Disorder
Polycystic Kidney Disease
Congenital Heart Defect
Down Syndrome
Other Chromosome Defects
Marfan Syndrome
Hemophilia
Sickle Cell Anemia
Thalassemia
Galactosemia
Deafness
Blindness
Colorblindness
Hemochromatosis
Other
What is your ancestry?
African-American
American Indian / Native American
Ashkenazi Jewish
Asian-American
Cajun / French Canadian
Caucasian
Eastern European
Hispanic/Caribbean
Northern European
Southern European
Other
Would you like additional screening for any of the following?
Cystic Fibrosis
Sickle Cell Anemia
Tay-Sachs Disease
Thalassemia
I confirm that I have reviewed the information above.
*
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This form was developed by the American Society for Reproductive Medicine to assist physicians and patients in obtaining a complete infertility history.
By submitting this form, I agree to receive SMS communications and marketing messages at the phone number provided above from Fertility Partnership via the phone number (636) 330-1126. I understand that in addition to responses to any queries I send to Fertility Partnership I may receive up to one marketing message per week. Data rates may apply. Reply STOP at any time to opt-out of all SMS messages from Fertility Partnership.
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