Medical Questionnaire

Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip code
E-mail*
Phone Number*

Area CodePhone Number
Date of Birth

MonthDayYear
Date
Date of Birth*

MonthDayYear
Married or in a long-term relationship?*

YesNo
# of children you have fathered*
Do you have any medical conditions?*

YesNo
Please explain what medical conditions and if you are taking any medications.
Have you had any scrotal surgeries or hernia repair?*

YesNo
Please select if you have a history of any of the following:

Hernia surgery as infant/child OR adultSurgery for undescended testicleSurgery for torsion or twisted testicleRemoval of a testiclePrior vasectomy or reversalother scrotal surgery
Please provide details if any of the above are checked
Are you allergic to any medications?
Please select if you are currently experiencing any the following:

Problems with bleeding or bruising?Difficulty getting or maintaining erections?Premature ejaculation?Difficulty reaching a climax?Tendency to get lightheaded or faint with medical procedures?
Please provide details if any of the above are checked
Do you have any other medical condition, injury or anything else we should be aware of that we have not mentioned?*

YesNo
Please provide details
Optional
What is your PCP's name.
How did you hear about our clinic?
Should be Empty: