Male History Form LA IVF Clinic

Please complete this Male History Form as accurately as possible at least three days prior to your Semen Analysis. Thank you.

You can also download a PDF of this form by clicking HERE and email a copy to info@laivfclinic.com or print and fax a copy to 310-691-1116.

Male History Form

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This field is for validation purposes and should be left unchanged.
Name*
First Last
Email
Height
Weight
Occupation
Do you have any medical problems?*
- Yes
- No
Have you had any surgeries?*
- Yes
- No
Any family history of any major illnesses?*
Please describe
Have you initiated any pregnancies in the past?
- Yes
- No
If yes, how many?*
Please enter a number less than or equal to 9.
Number with current partner?*
Please enter a number less than or equal to 9.
When was the most recent pregnancy?
Have you been evaluated by a Urologist?
- Yes
- No
If yes, what was the diagnosis?
Have you ever had a semen analysis?
- Yes
- No
Date of results of semen analysis
Results: Volume
(ml or cc):
Results: Count
(million/ml):
Results: Motility
(% moving sperm):
Results: Morphology
(% normal forms) - (Kruger's of WHO Criteria?)
Are you allergic to any medications ?
- Yes
- No
If yes, which medications?
What is your reaction to the medication?
Are you taking any medications?
- Yes
- No
Name of medication
Dose of medication
Frequency of medication
Do you use Tobacco?
- Yes
- No
How many packs a day?
Do you use Alcohol?
- Yes
- No
How many drinks per week?
Have you ever used drugs?
- Yes
- No
Do you use a hot tub or wear tight underwear?
- Yes
- No
How many times per week?
Have you had any of the following tests or procedures? : FSH
Date Result Comment
LH
Date Result Comment
Testosterone
Date Result Comment
TSH
Date Result Comment
Antisperm antibodies
Date Result Comment
DQ Alpha or HLA
Date Result Comment
Semen Tests: Hamster egg penetration
Date Result Comment
Semen Tests: Fructose
Date Result Comment
Semen Tests: Semen Culture
Date Result Comment
Surgery: Vasectomy
Date Result Comment
Vasectomy Reversal
Date Result Comment
Testicular Biopsy
Date Result Comment
Varicocele Surgery
Date Result Comment
Hernia Repair
Date Result Comment
Undescended Testicle
Date Result Comment
Removal of Testicle(s)
Date Result Comment
Other
Date Result Comment
PLEASE ENTER YOUR INITIALS TO SIGN THIS FORM
The undersigned declares that the above information is true and accurate:
Privacy*
- By using this form you agree with the storage and handling of your data by this website. *
I confirm that all the information I have entered is correct and I have read, understand that LA IVF CLINIC will contact me using the information provided.
- CONFIRM
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I consent to receive text messages, phone calls & emails with the information I have provided above. I also recognize that I can stop that communication at any time & La IVF Clinic will honor my request.
- I consent to receive text messages, phone calls & emails with the information I have provided above. I also recognize that I can stop that communication at any time & La IVF Clinic will honor my request.

Male History Form

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WEST LOS ANGELES

PASADENA

INLAND EMPIRE

San Diego

Call: (310) 286 2800

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