Download Male Reproductive Health Questionnaire

Welcome to UCSF Male Reproductive Health Practice at the
Center for Reproductive Health
To prepare for your initial consultation there are three things you need to do:
1. Complete the new patient questionnaire and bring with you on the day of your appointment.
Please arrive 15-20 minutes before your scheduled visit to complete all pre-visit paperwork
and check-in.
2. Bring your insurance card and photo ID
3. Call your insurance company* to verify coverage. Fertility treatment often has limited
coverage. Payment for services rendered at our clinic is required at the time of visit. We
accept: cash (in exact amounts only; the front desk cannot make change), personal checks,
VISA, MasterCard, American Express and Discover.
We are located at 2356 Sutter on the 3rd floor of the Women’s Health Center. Additional
detail can be found at: http://mountzion.ucsfmedicalcenter.org/map.html
If you need to cancel or reschedule your appointment, please call (415) 353-7131 at least 48
hours in advance.
Thank you for choosing the UCSF Male Reproductive Health Practice at the Center for
Reproductive Health.
* For Patients with HMO Insurance coverage:
In order to use your benefits, you will need to obtain AUTHORIZATION from your PCP (primary care
physician). Authorizations must be in place prior to your visit. We do not accept retroactive
authorizations. If you do not have this authorization at the time of visit, you will be responsible for full
payment; a referral is not an authorization.
** Due to the sensitive nature of our practice, we ask that you not bring children to our office.
2356 Sutter Street, 3rd Floor
San Francisco, CA 94115
www.ucsfivf.org
P#: 415.353.7131
F#: 415.885-3663
www.ucsfhealth.org
UCSF Center for Reproductive Health
Men’s Health Questionnaire
Patient name:
Street address:
City:
State:
Country:
Telephone:
E-mail:
Date of birth:
Partner’s name
Partner’s birthdate:
Zip:
County (e.g. Alameda):
Home:
Cell:
Work:
/
/
Age:
/
/
Age:
Primary MD Name:
Who referred you to the Center for Reproductive Health?
Physician:
Insurance company
UCSF website
Former patient / friend
Self
Reason(s) for Visit:
Fertility consultation
Vasectomy reversal consultation
Vasectomy consultation
Difficulty with erections
Peyronie’s disease
Other (please describe):
Phone: (
)
-
Phone: (
)
-
Ejaculation problems (e.g. rapid or delayed)
Low testosterone / low sex drive
Urination problems (e.g. slow stream, urgency)
Testicle or groin pain
Blood in the urine
Marital Status:
Married
Years married:
Domestic partnership
Years together:
Single
What is your racial and ethnic background? (Check all that apply)
African American/Black
Latino / Hispanic
American Indian or Alaskan Native
Middle – Eastern
Asian
Native Hawaiian or Pacific Islander
Caucasian / White
Other:
Work Status:
Employed full-time
Student
Employed part-time
Unemployed
Self-employed
Disabled
Retired
Other:
Place of Employment:
Job Title:
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Do you have any allergies to medications?
Medication:
Medication:
Medication:
Preferred Pharmacy:
Phone:
Current Medications
None:
Reaction:
Reaction:
Reaction:
Address:
Name
Dose
Frequency
1
2
3
4
5
6
7
8
9
10
Date Started
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
Past Medical History: Please select any illnesses that you may have/had.
How would you rate your overall health?
Anemia
Asthma
Bladder stones
Bleeding disorder
Blood in semen
Bowel problems
Bronchitis
Cancer (Type?):
Cystic fibrosis
Depression
Diabetes
Emphysema/COPD
Epididymitis
Epilepsy/Seizures
Fever (>101F) in last 3months
Genetic Condition
Describe:
GERD/frequent indigestion
Hay fever
Heart problems
High blood pressure
High cholesterol or triglycerides
Poor
Average
Good
Excellent
Immune disorder
Kidney disease
Kidney stones
Liver disease
Multiple sclerosis
Mumps
Peyronie’s disease
Prostatitis
Sexually transmitted infection
Sickle cell anemia/trait
Spinal cord injury
Stroke
Orchitis/Testicular infection
Testicle(s) undescended at birth
Testicular injury requiring hospitalization or surgery
Thyroid disease
Tuberculosis (TB)
Urethritis
Urinary tract infection
Vascular disease
Other:
Past Surgical History: Have you had any of the following surgeries?
Inguinal hernia repair
Varicocele surgery or embolization
Undescended testicle surgery
Cyst removal: testicular or scrotal
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Left
Left
Left
Left
2
Right
Right
Right
Right
Both
Both
Both
Both
/
/
/
/
DATE
/
/
/
/
Past Surgical History: Have you had any of the following surgeries?
Vasectomy
Vasectomy reversal
Pelvic surgery
Back surgery
Penile prosthesis
Prostate surgery for urinary blockage (e.g. TURP, laser prostate surgery)
Radiation with/without hormone treatment (Lupron) for prostate cancer
Prostate removed for cancer (i.e. prostatectomy)
Transplant: Which organ(s)?:
Bladder removed for cancer (i.e. cystectomy)
Other (please describe):
/
/
/
/
/
/
/
/
/
/
/
DATE
/
/
/
/
/
/
/
/
/
/
/
Family History: Briefly list any health issues
Mother:
Father:
Grandparents:
Maternal aunt:
Maternal uncle:
Paternal aunt:
Paternal uncle:
Brother:
Sister:
Social History:
Tobacco Use:
# Years Used
Current every day smoker
Current some day smoker
Former smoker
Non-smoker, exposed to smoke at home
Never smoker
Smokeless Tobacco:
/
/
/
/
Cigarettes
Cigars
Pipe
# Years Used
Current user
Former user
Never used
Amount /day:
Date quit:
Alcohol Use:
# of alcohol drinks/week:
No
Yes
Cans of beer
Drinks containing 0.5 oz of alcohol
Glasses of wine
Shots of liquor
Drug Use:
No
Yes
In the past
Anabolic steroids
Benzodiazepines
Cocaine
LSD
Sexual Activity
Not currently
No
Yes
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Tobacco Type:
Packs/day:
Packs/day:
Date quit:
No
Marijuana
Methamphetamines
Opiates
Other:
Partners
Female
Male
Both female and male
3
Yes
In the past
Review of Systems: Do you have any problems or symptoms in the following areas?
General
Psychiatric
Recent weight gain
Recent weight loss
Recurrent fevers, chills, sweats
Fatigue
Eyes
Glasses, contact lenses
Blurred or double vision
Glaucoma
Ear/Nose/Throat
Ringing in the ears
Bleeding gums
Genitourinary
Nervousness / anxiety
Depression
Insomnia
Skin
Changing moles
Skin cancer
Muscles and Joints
Joint stiffness or pain
Muscle pain or cramping
Weakness of muscles or joints
Back pain
Allergic Immunologic
Blood in the urine
Respiratory
Asthma/wheezing
Chronic cough
Frequent sinus infections
Heart Problems
Heart attack
Chest pain or angina
Palpitations
Swelling of feet, ankle, or hands
Gastrointestinal
Low resistance to infection
Recent cold or flu
Environmental allergies
Hematologic
Easy bruising
Enlarged lymph nodes
Blood clots in legs or lungs
Neurologic
Numbness or tingling sensations
Convulsions or seizures
Worsening memory/concentration
Decreased appetite
Severe heartburn
Varicose veins
Constipation
Endocrine:
Difficulty smelling?
Severe headaches?
Tunnel vision?
Reproductive History:
Do you have any children with your current partner?
Have you had children with any previous partners?
When did you stop using birth control? (mm/dd/yyyy)
When did you begin trying to get pregnant? (mm/dd/yyyy)
Are you timing intercourse with your partner’s cycles?
For how many months have you timed intercourse?
What fertility treatments have you used? (Select all that apply)
Clomid or medication for you
Clomid or medication for your partner
Vasectomy reversal
Varicocele surgery or embolization
Yes
Yes
No
No
/
/
Yes, monthly
How many?
How many?
/
/
Yes, occasionally
N/A
N/A
No
# Cycles
IUI: How many cycles?
IVF: How many cycles?
IVF / ICSI: How many cycles?
Other:
What form of birth control do you use currently or have you used most recently?
None
Condom
Birth control pills
IUD
If you have any children, please list their ages and gender:
Diaphragm
Rhythm (i.e. time intercourse to partner cycles)
Withdrawal (i.e. remove penis before ejaculation)
Other:
Age
Child #1
Child #2
Child #3
Child #4
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4
Male
Female
Is stress at work a significant problem?
No, no significant stress
Yes, stress is a small problem
Have you had exposure to any of the following:
Yes, stress is a moderate problem
Yes, stress is a big problem
Never
Yes, currently
Yes, in past
Chemicals or pesticides used to kill insects, rodents, or weeds?
Radiation for treatment of cancer?
Chemotherapy for treatment of cancer?
Industrial solvents or dyes?
Excessive heat in your work or hobbies?
Did your parents have difficulty conceiving or maintaining/carrying a pregnancy?
Did your siblings have difficulty conceiving or maintaining/carrying a pregnancy?
In the past three months, HOW OFTEN did you use hot tubs, saunas, or Jacuzzis?
Never
Less than once per month
A few times each month
Several days each week
Yes
Yes
No
No
Every day
No current partner (skip
partner history section)
Partner Fertility History
What is your partner's weight without shoes (lbs)?
What is your partner's height?
Are your partner's menstrual cycles regular?
Yes
No
On average, how many days are there from the first day of one menstrual cycle to the
first day of the next?
What is the total number of pregnancies, children, and
# Pregnancies
# Children
miscarriages your partner has had?
Has your partner had a fertility evaluation?
Yes
No
Did she have a normal HSG (hysterosalpinogram)?
Yes
No
What was her antral follicle count (AFC)?
After her fertility evaluation, was your partner diagnosed with any of the following?
None, no partner infertility problems found
Endometriosis
Polycystic ovary syndrome (PCOS)
Irregular ovulation
Blocked fallopian tubes
I don’t know
# Miscarriages
I don’t know
I don’t know
I don’t know
Fibroids
Hypothalamic or pituitary problem
Premature ovarian failure
Diminished ovarian reserve
Other (please specify)
Sexual History
How would you rate your libido (sex drive,
Terrible
Poor
Average
Good
Excellent
interest in sex)?
How strong are your
Extremely
Neither weak
Extremely
Weak
Strong
erections?
weak
nor strong
Strong
When did your difficulties with erections begin? (mm/dd/yyyy)
/
/
What do you think caused your erection problems?
On average, how many times do you have
0
1-2
3-4
5-6
7+
intercourse in a typical week?
Which medications or treatments have you tried to improve your erections? (Select all that apply)
Intraurethral suppository (“MUSE”)
Penile injections
Penile prosthesis
Other:
None
Herbal therapies, Chinese medicine
Oral medications (e.g. Viagra, Cialis, Levitra)
Vacuum erection device
Do you use any of the following lubricants for intercourse? (Select all that apply)
Preseed
KY jelly (or other commercial lubricant)
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Mineral oil
Egg whites
5
Olive oil or other vegetable oil
Other:
Some people have sexual relationships with men, some with
Women and
women, and some with both. Have you had sexual
Women only
Men
relationships with:
Straight,
Gay,
How do you identify yourself?
Bisexual
heterosexual
homosexual
Over the past six months, considering your
general experiences with sex, how
No
Somewhat
Moderately
Very
distressed have you been by these
distress
distressed
distressed
distressed
experiences?
How many hours per week do you ride a
0
1-2
3-4
5-6
bicycle?
While riding your bike, how often do you
experience numbness in your groin or penis?
Less than ½
the time
Never
½ the
time
Men only
Other
Extremely
distressed
7+
More than ½
the time
Every
time
Sexual Health Inventory for Men (SHIM)
Over the past 4 weeks…
How often were you able to get an
erection during sexual activity?
When you had erections with sexual
stimulation, how often were your
erections hard enough for
penetration?
During sexual intercourse, how
often were you able to maintain
your erection after you had
penetrated (entered) your partner?
When you attempted sexual
intercourse, how often was it
satisfactory for you?
During sexual intercourse, how
difficult was it for you to maintain
your erection to completion of
intercourse?
How did you rate your confidence
that you could get and keep an
erection?
SHIM Total:
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Almost
never /
never
A few times
(much less
than ½ the
time)
Sometimes
(about ½ the
time)
Most times
(much more
than ½ the
time)
Almost
always /
always
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
Extremely
difficult
Very difficult
Difficult
Slightly
difficult
Not difficult
1
2
3
4
5
Very low
Low
Moderate
High
Very high
1
2
3
4
5
6
The following questions refer to your general experience with intercourse. Circle the appropriate answer.
On average, how long does intercourse last form
the time your penis enters your partner to the
< 1 minute
1-5 minutes
5-10 minutes
10+ minutes
time you ejaculate?
Not difficult at
Somewhat
Moderately
Very difficult
Extremely
all
difficult
difficult
difficult
How difficult is it for you to delay
1
2
3
4
5
ejaculation?
Almost never
Less than ½
More than ½
Almost always
½ the time
or never
the time
the time
or always
Do you ejaculate before you want to?
1
2
3
4
5
Do you ejaculate with very little
1
2
3
4
5
stimulation?
Not at all
Slightly
Moderately
Very
Extremely
frustrated
frustrated
frustrated
frustrated
frustrated
Do you feel frustrated because of
1
2
3
4
5
ejaculating before you wanted to?
Not at all
Slightly
Moderately
Very
Extremely
concerned
concerned
concerned
concerned
concerned
How concerned are you that your time
to ejaculation leaves your partner
1
2
3
4
5
sexually unfulfilled?
PEDT Total:
Urinary History
Circle 1 number on each line
Over the past month or so, how often have
you had a sensation of not emptying
your bladder completely after you
finished urinating?
During the past month or so, how often
have you had to urinate again less than
two hours after you finished urinating?
During the past month or so, how often
have you found you stopped and started
again several times when you urinated?
During the past month or so, how often
have you found it difficult to postpone
urination?
During the past month or so, how often
have you had a weak urinary stream?
During the past month or so, how often
have you had to push or strain to begin
urination?
Over the past month, how many times per
night did you most typically get up to
urinate from the time you went to bed at
night until the time you got up in the
morning?
Not at
all
Less than 1
time in 5
Less than
½ the time
About ½
the time
More than
½ the time
Almost
always
0
1
2
3
4
5
0
1
2
3
4
5
0
1
2
3
4
5
0
1
2
3
4
5
0
1
2
3
4
5
0
1
2
3
4
5
None
1 time
2 times
3 times
4 times
5+ times
0
1
2
3
4
5
Mostly
dissatisfied
Unhappy
AUASS Total:
Delighted
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Pleased
7
Mostly
satisfied
Mixed
Terrible
How would you feel if you had to live
with your urinary condition the way
it is now, no better, no worse, for the
rest of your life?
1
0
2
3
4
5
6
No pain, skip this section
Pain History
When did your pain begin (mm/dd/yy)?
/
/
Please mark the location(s) of your pain
on the diagram.
What do you think caused your pain?
Using the scale below, how intense is the pain at its worst?
Over the past 4 weeks, how intense is the pain on average?
How would you describe your pain? (Select all that apply)
□
Sharp (like a knife)
□
Ache (like a tooth)
□
Pulling or pressure
□
Burning
□
Shooting
□
Comes and goes
□
Throbbing
□
Pinching
□
Constant, with me all the time
What makes the pain worse?
What makes the pain get better?
Have you tried any of the following medications or treatments for your pain?
□ Anti-inflammatory medications (e.g.
ibuprofen, naproxen)
□ Narcotic pain medication (e.g. codeine,
vicodin, hydrocodone)
□ Anti-depressant medication (e.g. paxil,
celexa, nortriptyline)
□ Antibiotics (e.g. ciprofloxacin,
doxycycline)
□ Gabapentin/Neurontin
□ Acupuncture, Chinese medicine,
naturopathic medicine
□ Spermatic cord block
□ Physical therapy
□ Spinal block
□ Other:
Have you had a scrotal ultrasound?
□
□
Yes
What did this show?
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No