• Family Holistic Reproductive Health Associates

    Male Fertility Intake Form
    To be completed before your initial consultation

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    For the most accurate evaluation, please complete the form below carefully and thoroughly. Your privacy will be strictly protected (see our Privacy Policy).

    PATIENT INFORMATION

    Your Full Name:

    Age:
    Date of Birth:
    Weight:
    Height:
    Marital Status: single married divorced widowed
    Occupation:
    Email:
    Phone:
    Home Address:
    Employed By:
    Employer's Address:
    Emergency Contact & Relationship:
    I understand that I should be evaluated by a physician for the condition I am requesting consultation. The diagnosis and treatment plan I will be given by FHRHA is based upon Traditional Chinese medical principles and natural treatment only, and does not constitute a western medical diagnosis. I understand that I am not to rely on Traditional Chinese diagnosis and treatment as my sole remedy for the treatment I am seeking. I understand if no substantial improvement is made in the condition for which I am seeking consultation. I am to seek advice from a Western medial doctor. Further, if I am concurrently undergoing Western medical treatments, it is my responsibility to advise by physician of any herbal supplements I am concurrently taking.
    I have read and understand the above statement:
     Please type YES as your signature:   
    Today's Date: 

    How did you hear about us:

     
    MEDICAL HISTORY

    Major complaint / health issue?

    How did this condition develop?

    How long has this condition persisted?

    What makes it better / worse?

     Have you seen a physician for the condition? If yes, by whom and what was the diagnosis?

    What medicine or treatment has your physician prescribed for the condition & how well did you respond to it?

    Have you seen a Chinese herbal doctor or an acupuncturist for the condition?

    Have you taken any herbal remedy for the condition? What are they, the dosage, and for how long? How did you respond to them?

    List all allergies:

    List all medications you are currently taking (include dosage and for how long):

    List all surgeries (include date and reason):

    List all significant traumas (auto accidents, falls, etc...):

    SIGNIFICANT ILLNESSES (PLEASE CHECK ALL THAT APPLY)

    Arthritis:
    Asthma:
    Autoimmune    :
         AIDS:
         Cancer
    Diabetes:
    Gallstones:
    Heart Disease:

    Kidney stones:
    Rheumatic fever:
    Ruptured Appendix:
         Seizures:
         Thyroid Disease:
    Venereal Disease:
    Hepatitis:
    Hypertension:
    Connective tissue disorders:
    Other
    MEN'S FERTILITY HISTORY

    How long have you and your partner been trying to conceive?

    How would you define your sexual energy?   Below Normal    Normal  

    Do you have an undescended testes? yes    no

    Have you ever been diagnosed with a varicocele?  yes    no

    Have you had any urologic surgeries? yes    no

    Have you experienced difficulty maintaining erection? yes    no

    Have you experienced difficulty ejaculating?  yes    no

    Have you had exposure to any known environmental toxins or hormones?  yes    no

    Have you experienced any penile discharge? yes    no

    Do you regularly experience nocturnal emission?  yes    no

    Have you had a fertility workup?  yes    no

    If yes, what was your sperm count? 

    What was the sperm motility?

    What was the sperm morphology? 

     

    Male Fertility Worksheet - (check all that apply)
    KI YI-
    Lower back weakness, soreness or pain, or knee problems:
    Ringing in ears or dizziness    :
    Prematurely gray hair:
    Dark circles around or under your eyes:
    Night sweats:
    Hot flashes:
    Fearful:
    		KI YA-
    Low back sore or weak
    Cold feet, especially at night:
    Colder than those around you
    Low libido:
    Often fearful
    Wake up at night or early a.m. to urinate
    Frequent profuse urination:
    SP-
    Often fatigued:
    Poor appetite    :
    Energy lower after a mealr:
    Bloated after eating:
    Crave sweets:
    Loose stools, abdominal pain or digestive problems:
    Cold hands anf feet:
    Cold nose:
    Feel heavy or sluggish:
    Bruise easily:
    Poor circulation    :
    Varicose veins:
    Lacking strength in arms & legs:
    Lacking in exercise:
    Prone to worry:
    Low blood pressure:
    Sweat easily:
    Dizzy or lightheaded on standing:
    Allergies, frequent colds:
    Hypothyroid, Anemia:
    Hemorrhoids or polyps:

    BL X

    Periodic numbness of hands & feet:
    Varicose or spider veins:
    Red hemangiomas (cherry red spots) on skin:
    Chronic hemorrhoids:
    Tender lower abdomen:
    Lumps in lower abdomen:

    BL-

    Dry, flaky skin    :
    Prone to Chapped lips:
    Brittle nails:
    Diminished nighttime vision:

    LR-Q
    Prone to emotional depression
    Prone to anger/rage
    Difficulty falling asleep at night
    Heartburn or bitter taste in mouth
    Dull Ache in right ribcage area     		H-
    Wake up early & can't get back to sleep
    Heart palpitations esp when anxious
    Nightmares:
    Low spirit/vitality
    Agitation or extreme restlessness:
    Fidgetting
    Excessive sweating esp on your chest

    Usually dry mouth and throat:
    Thirsty for cold drinks    :
    Feel warmer than those around you:
    Wake up sweating or have hot flashes:
    Break out with red acne esp when stressed:

    Tired & sluggish after a meal:
    Cystic or postular acne:
    Urgent, foul smelling stool:
    Achy joints upon movement:
    Overweight    :

     
    Do you have a partner with whom you have been trying to conceive? yes    no
    How long have you been married or living together?
    Are you using donor sperm either because you have a female partner, or your male partner has fertility issues?yes    no
    How long have you been trying to conceive?
    Is your partner supportive of your wishes to conceive?yes    no
    Have either of you had a Western medical diagnosis relating to infertility?yes    no
    If Yes above, what was it?
    By whom?

    Have you had any hormone laboratory test performed?yes    no
    Prolactin  Normal  High
    Thyroid  Normal  High  Low
    Progesterone  Normal  High  Low
    Testosterone  Normal  High  Low
    Other           Normal  High  Low

    Have you ever received chemotherapy or radiation?yes    no
    How is your sexual desire (mental interest) Low  Normal  High
    How is your sexual arousal response (physically aroused/orgasm)?  Low  Normal  High
    Are you more than 20% over your ideal body weight?yes    no
    Do you exercise regularly?yes    no
    Do you have a stressful occupation?yes    no

    Do you have other comments on your reproductive health?

    Please scroll up to the top and double check what you have completed and correct any error before submission.

     Ensure you submit to the correct physician.