The ART Institute of Washington, Inc. at Walter Reed Army Medical Center MALE PATIENT HISTORY Date Completed I. PATIENT INFORMATION Name Partner's Name Date of Birth Partner's Date of Birth Phone Number Day Phone Number Evening Address City Current Occupation Email Address State Zip Code Il. GENERAL MEDICAL HISTORY Height (inches) Weight (lbs) Do you follow a particular food diet or have special dietary habits Do you exercise regularly Yes Yes Have you lost >20 lbs this year No Yes No Primary Exercise Have you ever had surgery of the pelvis, scrotum, testicles No Hours/Week Yes No Specify Date/Type of Surgery Do you have or have you ever had (check all that apply): Anemia Appendicitis Arthritis Blood Transfusion Breast Discharge Breast Soreness Cancer (see below)* Chlamydia Chronic Bonchitis Colitis Cystic Fibrosis Diabetes Dizziness Epilepsy Gallbladder Problems Gonorrhea Heart Disease Hepatitis Herpes Mumps High blood pressure Kidney infection Kidney Stone Liver Problems Loss of Balance Vasectomy Neurological Problems Urethritis Prostatitis Testes Infection Testes Trauma Pneumonia Poor sense of smell Rheumatic fever Scarlet Fever Seizures Syphilis Thyroid problem Tuberculosis Ulcers Testes Surgery Varicocele Visual Disturbance Other medical problem** *Type of Cancer, diagnosis and treatment dates Have you ever received chemotherapy Yes No Have you ever received radiation therapy Yes No **Other medical problem (list) Do you frequently take saunas or steam baths No Yes Have you had a high fever (>102F) in the past 3-4 months Yes No Are you taking any prescription or over-the-counter medications Yes No List All Medications Do you have any allergies (medication, latex, food) Yes No List Allergies (and reaction) Page 1 of 3 This form is not to be used or reproduced without the expressed written consent of the ART Institute of Washington, Inc. Do you use or have you ever used (check all that apply): Alcohol Yes No How many glasses/Drinks per week Tobacco Yes No Number of packs per day Illicit or Recreational drugs No Yes Years of tobacco use If you would be more comfortable not writing anything down, please discuss this directly with your physician. Explain III. EXPOSURE HISTORY Are you or have you ever been exposed to any of the following during employment or military service (check all that apply): Heat Chemicals Toxic Fumes Nuclear Radiation Other Specify Do you currently or have you ever used workout supplements other than vitamins (steroids, DHEA-S, androstendione, creatine, prohormones, etc). Specify and note dates of use. IV. REPRODUCTIVE/SEXUAL HISTORY How long have you and your partner been trying to get pregnant How many times per week do you have sexual intercourse How many times do you have intercourse around her ovulation Are you circumcised Yes No When you were born, were both testes descended in the scrotum Have you ever fathered a child Yes No Yes No How many children No Yes Do you have trouble getting or keeping an erection Do you have trouble with ejaculating (premature, retrograde, unable) Have you noticed a decreased in sexual drive Yes No Yes Do you ever have orgasms with masterbation without ejaculation No Yes Do you have any discharge from the penis No Yes No At what age did you start shaving regularly or start to grow a beard Have you ever had a varicocele repair Yes No Have you ever had a vasectomy reversal or repair Yes Have you ever had a surgical retrieval of sperm (MESA, TESE) Have you ever been treated for infertility before Yes No No Yes No What cause of infertility was diagnosed Have you and your partner undergone Intrauterine Insemination (IUI) Have you and your partner undergone In-Vitro Fertilization (IVF) Is your partner seeing a physician for female infertility Yes Yes Yes No No Total Number of IUIs Total Number of IVF Cycles No What is your partner's infertility diagnosis Has your partner had a child with another man Yes No This form is not to be used or reproduced without the expressed written consent of the ART Institute of Washington, Inc. Page 2 of 3 Which of the following tests have you had performed? Check all that apply and the results/dates if known: Hormone Assay (FSH, LH, progesterone, estrogen) Androgen levels (testosterone, DHEA-S) Glucose/insulin Chromosome/Karyotype Semen Analysis Ultrasound of the scrotum Thyroid function Testicular Biopsy Hamster egg test Chlamydia test Other What drugs have you taken for infertility? Check all that apply: Clomiphene Citrate (clomid) hMG (pergonal, menopur) Tamoxifen Testalactone GnRH (lupron) hCG (ovidrel) FSH (gonal-F, bravelle) Danazol (danocrine) Bromocriptine (parlodel) Steroids (prednisone, dexamethasone) Letrozole Other V. FAMILY HISTORY Is there a family history of infertility Yes Is there a family history of hormonal disorders No Yes Specify No Specify VI. ADDITIONAL INFORMATION Please provide any additional information or use this space to elaborate on any of the above questions. Print Form This form is not to be used or reproduced without the expressed written consent of the ART Institute of Washington, Inc. Page 3 of 3