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Gynaecology Infertility Note (Male)

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Occupation

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Pregnancies Fathered

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This Union

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Previous Union

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Months Since Last Fertilisation

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PREVIOUS INVESTIGATIONS AND TREATMENTS FOR INFERTILITY

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Investigations

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Treatment

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MEDICAL AND SURGICAL HISTORY WITH POSIBBLE ADVERSE EFFECTS ON FERTILITY

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Systemic Disease

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Febrile Illness (38 c) In the Last 6 Months

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Medical Treatment

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Allergies And Alert

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Surgical Procedures

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Urinary Infection

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Std

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Epididymitis

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Pathology Possibly Contributing To Testicular Damage

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Others, Specify

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Varicocele

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Mode Of Treatment

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Complication

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Age At Treatment

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Post Treatment

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Semen Analysis

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Comments

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Testicular Maldescent

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Mode Of Treatment

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Complication

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Age At Treatment

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Post Treatment

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Semen Analysis

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Comments

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OTHER FACTORS WITH POSSIBLE EFFECTS ON FERTILITY

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Environmental

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Diet

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Smoking

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Alcohol

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Drug Abuse

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Risk Factors (HIV / Hepatitis)

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Relevant Family History

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SEXUAL HISTORY OF BOTH PARTNERS

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Coital Frequency

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Knowledge Of Fertile Period

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Use Of Fertile Period

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Dyspareunia

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Erection

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Ejaculation

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