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.*
First Last
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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