Clinic History Male

Clinical History Of The Male Partner

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CLINICAL HISTORY OF THE MALE PARTNER

**PLEASE FILL IN THIS FORM IN CAPITAL LETTERS**

Please leave blank any questions you do not understand or are not sure of how to answer.
We ask you to pay close attention when filling in this questionnaire, as your answers are very important. All information is confidential and will be considered as apart of your medical history.






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





2. PERSONAL MEDICAL HISTORY (PAST OR PRESENT):
















































4.PREVIOUS PREGNANCIES WITH YOUR CURRENT PARTNER

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

YesNo



5. PREVIOUS PREGNANCIES WITH A DIFFERENT PARTNER:


YesNo





6. TEST RESULTS OF THE MALE PARTNER:

RECENT SPERM ANALYSES:

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













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