INFERTILITY

INFERTILITY

PATIENT QUESTIONNAIRE (Version 06.08.23)
Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
1. How long have you and your partner been attempting to conceive?*
2. How many biological children do you have?*

012345
3. What is the age of your current partner with who you are trying to achieve pregnancy?*
4. How many biological children does your partner have?*

01234>4
5. Has your partner been evaluated for infertility?*

YesIs currently undergoing evaluationNo
6. Have you ever? Check all that apply*

Used testosterone therapyHad a vasectomyReceived chemotherapyHad undescended testiclesHad a sexually transmitted diseaseHad an infection of the testiclesHad an infection of the prostateHeavy exposure to chemical solventsNone of the above
7. Are you and your partner currently seeing a reproductive endocrinologist?*

YesNo
If your answer to question #7 is YES, then please move on to question #8.

If NO, then move straight to question #9.
8. Who is your reproductive endocrinologist?
9. Have you ever received treatment for infertility?*

YesNoDon’t know
If your answer to question #9 is Yes continue to Q10.

If No, end survey.
10.What treatments have you tried for male infertility? (Select all that apply)

Vitamin supplementsLifestyle changes (changed eating habits or adopted and exercise regimen)Varicocelectomy (repair of varicocele)Intrauterine insemination (IUI)In-vitro fertilization or intra-cytoplasmic sperm injection (IVF/ICSI)Testicular sperm extraction (TESE)
Patient or Representative Signature

Powered by Jotform SignClear
Date

MonthDayYear
Date
Should be Empty: