Your name:

 

Date of Consultation:
 

PERSONAL HISTORY:
 

Marital Status: _______________

 

Number of Children: _______________

 

Present Birth Control Method: _______________

 

Occupation: _______________

 

Family Physician / Referring Physician Name: _______________
 

PAST MEDICAL HISTORY:
 

Do you suffer from any medical condition (for example Diabetes, hepatitis, HIV): _______________

 

Any past operations (especially if on testicles or in the groin region): _______________
 

Any trauma/ injuries (particularly to the testicles or genital area): _______________
 

Any drug allergies/ reactions: _______________
 

Any medications taken regularly (particularly blood thinners like Aspirin): _______________
 

SEMEN ANALYSIS TESTING:
 

We suggest a semen analysis test be taken 10-12 weeks following your procedure to be sure your

procedure was successful. We receive the results approximately 8-10 days following your

submission and we will contact you with the results.
 

Can we leave a message with your test results on your answering machine? _____

 

Can we give test results to someone at your residence? _____