Clinic History Male

NAME AND SURNAME:

EMAIL :

DATE OF BIRTH:

DURATION OF INFERTILITY :

1. FAMILY HISTORY:

Among the members of your family (parents, brothers and sisters, aunts and uncles, children, nieces and nephews), is there any history of

HEREDITARY DISEASES:

CHILDREN BORN WITH DEFORMITIES:

OTHER RELEVANT HEALTH CONDITIONS:

2. PERSONAL MEDICAL HISTORY (PAST OR PRESENT):

GENETIC DISEASE:

HEALTHY CARRIER OF A HEREDITARY DISEASE :

OTHER TYPES OF ANEMIA:

CANCER:

INFECTIOUS DISEASES :

PELVIC/GENITAL INFECTIONS:

MUMPS WITH TESTICULAR INFLAMMATION:

OTHER TYPES OF TESTICULAR OR EPIDIDYMAL INFLAMMATION:

PROSTATITIS:

TESTICULAR TRAUMA:

UNDESCENDED TESTICLE WHICH SIDE? (TREATMENT(HORMONAL / SURGICAL, ATWHATAGE )):

UNI/BILATERAL ABSENCE OF TESTICLES/VASDEFERENS:

VASECTOMY:

UNI/BILATERAL VARICOCELE:

ANY PROBLEMS RELATED TO EJACULATION PREMATURE EJACULATION( TOOSOON ), RETROGRADE ( DRY )EJACULATION, OTHER DIFFICULTIES :

PROBLEM SWITHLIBIDO:

CHRONIC BRONCHITIS:

CHRONIC SINUSITIS:

DIABETES::

NEUROLOGICAL, PSYCHOLOGICAL, PSYCHIATRIC DISORDERS, DEPRESSION, ANXIETY:

EPILEPSY:

DELAYED-PUBERTY ORHYPOGONADISM:

BLOOD-INURINEORSEMEN:

ERECTION-PROBLEMS:

THROMBOSIS:

HEART DISEASE:

HYPERTENSION (HIGH BLOOD PRESSURE):

THYROID DISORDERS:

ASTHMA:

NEPHRO-UROLOGICAL DISORDERS:

HEPATOPATHIES (LIVER DISEASES):

GASTRIC/DUODENAL ULCERS:

CROHN'S DISEASE:

TUBERCULOSIS:

VASCULAR CEREBRAL EVENTS:

MULTIPLE SCLEROSIS:

OTHER RELEVANT HEALTH CONDITIONS:

ALLERGIES TO MEDICATIONS/LATEX/METALS:

REACTIONS TO ANESTHETICS:

MEDICATIONS TAKEN IN THE LAST 6 MONTHS:

SMOKING HABITS (CIGARS/CIGARETTES PER DAY):

ALCOHOL CONSUMPTION (GLASSES PER DAY):

DRUG CONSUMPTION:

PREVIOUS SURGERIES :

EXPOSURE TO HIGH TEMPERATURE OR TO TOXINS AT WORK IN ANY OTHER ACTIVITY:

4.PREVIOUS PREGNANCIES WITH YOUR CURRENT PARTNER

4.PREVIOUS PREGNANCIES WITH YOUR CURRENT PARTNER:

IF YES,HOW LONG DID IT TAKE HER TO GET PREGNANT?

YesNo

IF YES,HOW LONG DID IT TAKE HER TO GET PREGNANT?

5. PREVIOUS PREGNANCIES WITH A DIFFERENT PARTNER:

PREVIOUS PREGNANCIES WITH A DIFFERENT PARTNER:
YesNo

IF YES,HOW LONG DID IT TAKE HER TO GET PREGNANT? :

DID THE OTHER PARTNER HAVE ANY DIFFICULTIES GETTING PREGNANT? :

IF YOU HAVE CHILDREN FROM YOUR PREVIOUS RELATIONSHIP(S), WHAT IS THE IRAGEAND SEX? ARE THEY HEALTHY? :

6. TEST RESULTS OF THE MALE PARTNER:

RECENT SPERM ANALYSES:

Date	CONCENTRATION (MILLION SPERM CELLS/ML)	MOTILITY A+B%	NORMAL FORMS%

HORMONAL TESTS(FSH,LH,PROLACTIN,TESTOSTERONE):

URINE/SEMENCULTURE:

TESTICULAR/PROSTATICULTRASOUND/DOPPLERSTUDY:

KARYOTYPE(CHROMOSOMEANALYSIS):

MICRODELETIONS OF CHROMOSOMEY:

UNI/BILATERAL TESTICULAR BIOPSY:

SPERM FREEZING:

OTHERTESTS(PLEASESPECIFY):

Date: