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 firstname.lastname@example.org or print and fax a copy to 310-691-1116. Male History Form 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 describeHave 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? MM slash DD slash YYYY 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 MM slash DD slash YYYY 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? : FSHDateResultComment LHDateResultComment TestosteroneDateResultComment TSHDateResultComment Antisperm antibodiesDateResultComment DQ Alpha or HLADateResultComment Semen Tests: Hamster egg penetrationDateResultComment Semen Tests: FructoseDateResultComment Semen Tests: Semen CultureDateResultComment Surgery: VasectomyDateResultComment Vasectomy ReversalDateResultComment Testicular BiopsyDateResultComment Varicocele SurgeryDateResultComment Hernia RepairDateResultComment Undescended TesticleDateResultComment Removal of Testicle(s)DateResultComment OtherDateResultComment 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 CAPTCHAPlease enter your email to receive a copy of this Questionnaire PhoneThis field is for validation purposes and should be left unchanged.