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Maleinfertility_ucna
MALE INFERTILITY
PATIENT QUESTIONNAIRE
UROLOGIC CLINICS OF NORTH ALABAMA
Name:__________________________Age:________Race:__________
Occupation:______________________ Referred by: _______________
Reproductive History:
1. Do you have any children? Yes/ No, If yes how many ____Ages_________
2. Duration of unprotected intercourse?________________________________
3. How old is your partner?_________yrs
4. Does your partner have any children? Yes/ No
5. Has your partner had any miscarriages/abortions?
If yes, detail________________________________________________
6. Has your partner been evaluated for this problem? Yes/ No,
If yes, results_______________________________________________
Sexual History:
1. Timing/ frequency of intercourse?___________________________________
2. Problems with erections? If yes detail_______________________________
3. Problems with ejaculations?_______________________________________
4. Use of lubricants? Yes/ No, If yes name_______________________________
Developmental History:
1. Onset of Puberty___________________________________________
2. Age when you started shaving._____ Do you shave everyday? Yes/ No
3. Any delay in development? Yes/ No, If yes detail__________________
Male infertility questionnaire
Page two
Medical History:
1. Any childhood illnesses? (Circle any that apply) None_____
g. other__________________________________________________
Notes____________________________________________________________________________________________________________________
2. Any other illnesses? ( Circle all that apply) None______
e. other_________________________________
Notes_____________________________________________________________________________________________________________________
3. Medications: (Circle all that apply) None_____ Have you ever been on
Notes_____________________________________________________________________________________________________________________
Please list all the medications you are on,
including over the counter and herbal medications. None_________
Notes _______________________________________________________
____________________________________________________________
Male infertility questionnaire Page three
Surgical History:
h. epididymal surgery i. Testicular biopsy
Notes _________________________________________________________
______________________________________________________________
List all other surgeries and their complications if any:
Personal History: (Please circle one)
Do you or have you ever had alcohol? Yes/ No
Do you or have you ever used recreational drugs?
Notes____________________________________________________
Any additional comments__________________________________________
______________________________________________________________
______________________________________________________________
Patient Signature:__________________________________ Dated______________
Name:_______________________________ Age:____________________
Urinalysis:
L
eukocytes:____Nitrite:____Urobilinogen_____Protein:______Blood:___________Sp.Gravity:________pH:________
K etone:_______Bilirubin:_______Glucose:__________WBC:_______RBC:_______Yeist:______Bacteria:_________
Ep.Cells:_______Crystals:________Casts:_________Other:__________
Physical Examination
1. General ( means normal) BP:__________ Pulse:_______ RR:________
Temp:_________ Height:___________ Weight:_____________
a. Nutrition_____ b. body habitus_______
d. gynecomastia_______ e. secondary sexual characters__________
Urethral opening_______ Plaques_______ Size________
Semen Analysis: Has a semen analysis been done? If yes results.
Notes:__________________________________________________________
_________________________________________________________
_________________________________________________________
Impression: 1.________________________ 2.________________________
2._____________________________ 3._______________________
Signed ______________________________ Date: ___________________
Source: http://www.ucna.com/maleinfertility_ucna.pdf
International Journal of Ethnomedicine and Pharmacological Research (2013), Vol.1, Issue 2, P. 151-154 ISSN No. 2347 - 2901 (Print) 2347 - 291X (Online) International Journal of Ethnomedicine and Pharmacological Research © 2013 by the International Journal of Ethnomedicine and Pharmacological Research Evaluation of Acalypha fruticosa and Andrographis peniculata alkaloid extra
PYODERMITES AMVQ/CAVD, 18 novembre 2007 Manon Paradis, DMV, MScV, Dipl. ACVD, Département de sciences cliniques, Faculté de médecine vétérinaire, Université de Montréal, St-Hyacinthe, Québec, Canada. 1- INTRODUCTION Chez le chien, les infections bactériennes de la peau sont fréquentes et pléomorphes, tandis qu'elles sont rarissimes chez le chat (exception faite des abcè