Fertility Worksheet - Men

This worksheet is to be filled out by men coming to Acupuncture Northwest for fertility issues. If you'd prefer the print version of this form, click here.

Patient First Name

Patient Last Name

Gender

Phone

Email Address

Partner First Name

Partner Last Name

Partner Gender

How long have you been trying to get pregnant?

Do you have a diagnosis of infertility?

When was that diagnosis given?

Diagnosis, Male Factor?

Diagnosis, Female Factor?

Any other related diagnoses?

What fertility treatments have you tried, when and what happened?

What	When	Where/By Whom

How would you define your sexual energy?
Below Normal Normal High

Do you have any undescended testes?
Yes No

Have you ever been diagnosed with a varicocele?
Yes No

Have you had any urologic surgeries?
Yes No

Have you experienced difficulty maintaining erection?
Yes No

Have you experienced difficulty ejaculating?
Yes No

Have you had exposure to any known environmental toxins or hormones?
Yes No

Have you experienced any penile discharge?
Yes No

Do you regularly experience nocturnal emission?
Yes No

Have you had a fertility workup?
Yes No

If yes, what was your sperm count? Below Normal Normal

Number

What was the sperm motility?
Below Normal Normal

Notes

What was the sperm morphology?
Below Normal Normal

Notes

What is your plan from here?

Please bring all relevant lab work with you to your first appointment.

Just wanted to Thank You for everything!!! I am Pregnant !! now 10 weeks. So far so good..but I am thinking that I will probably need some acupuncture later on for my back/siatiac nerve..just feeling like later that will be a problem. Again I thank you for everythingâ€¦I truly believe that the acupuncture had something to do with my positive results. I have referred some others to you from my fertility support group.
Nicole
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Fertility Worksheet - Men

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