| Male fertility worksheet |
 Getting pregnant can be difficult!
Go to any doctors appointments together!
Bring copies of your health records to your visit and have copies sent to your doctor ahead of time to avoid the hassle and expense of duplicating medical tests. Expect to be asked about your sexual history, whether you've ever had any sexually transmitted infections, how often you make love, and more. Not much about your private life will be private anymore, so you'll want to feel comfortable with your doctor.
Print this worksheet, fill it out, and give to your doctor.
Name:
Date of birth:
Partner's name:
Partner's date of birth:
Weight:
Height:
Current medications:
MEDICAL HISTORY:
Were you born with undescended testicles?
Have you had an illness accompanied by a high fever in the last six months?
Have you noticed swelling or pain in one or both testicles recently? Have you sustained any injuries to your testicles? Have you ever had a testicular torsion?
Have you ever had a tumor or cyst in your testicles?
Have you had any X-rays to your groin area?
Do you have chronic bladder or urinary tract infections? Is your urine cloudy, or do you feel a burning sensation when urinating?
Have you ever had cancer requiring chemotherapy or radiation therapy?
Do you have any chronic illness such as diabetes or thyroid disease?
Do you take any medications?
Have you had the mumps? How old were you when you caught them?
Are you a Gulf War veteran? Were you ever exposed to any toxins such as Agent Orange?
SEXUAL HISTORY:
Have you ever tested positive for a sexually transmitted infection? Which one?
Have you had a vasectomy? Or a reversal?
Do you have any difficulty getting or maintaining an erection?
Do you have any problems ejaculating?
Are you having any sexual difficulties? Please explain:
FAMILY HISTORY:
Have any members of your family had problems with abnormal births or stillbirths?
LIFESTYLE HISTORY:
(Some studies suggest that lifestyle factors may affect fertility.)
Do you drink alcohol? How many drinks do you have per week?
Do you smoke? How many packs of cigarettes do you smoke a week?
Do you take hot baths or use hot tubs?
Are you a frequent bike rider? How often do you ride?
Do you work with chemicals, radiation, or around high levels of heat? |
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First draft of the AFI Training Manual on tackling abusive behaviour. Comments, additions, improvements welcome!
