Medical Intake Form | Dads Again "*" indicates required fields Required Medical History IntakeTakes about two minutes to complete! Please, put "Not Applicable" for any required fields that do not apply to you.Name:* First Last Phone:*Email:* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Date of Birth:* MM slash DD slash YYYY Years Since Vasectomy:*Please enter a number from .5 to 50.Biological Children's Ages (him):*Wife or Significant Other's Name:*Wife or SO's Age:Her Phone #:Do you and your wife / SO share children?* Yes No Not Applicable Biological Children's Ages (her):*LifestyleDo you smoke?*Please, provide details such as what you smoke, how often, etc.Do you drink alcohol?*Please, provide details such as what you drink, how often, etc.Are you currently taking testosterone? Have you ever taken testosterone?*Please, provide details such as when you started, the dosages, how often, etc.What strenuous activities do you take part in on a daily, weekly, monthly basis?*What vitamins or supplements are you currently taking?*Please, provide details such as what you are taking, the dosages, how often, etc.Medical HistoryWhat medications are you currently taking?*Please, provide details such as what you are taking, the dosages, how often, etc.Please, list all of your allergies:*Please, list all of your medical issues: (Asthma, Heart Disease, Sleep Apnea, Cancer, etc.)*Please, list all of your previous surgeries with years / dates:*List all previous scrotal injuries, infections, and vasectomy details/complications:*(Was it a scrotal incision? Were there 2 incisions made? Were there any complications with your vasectomy?)Communication with the office of International Center for Vasectomy Reversals:Preferred Method of Contact:*Best time to reach you:*Do you give us permission to leave you voicemails?* Yes No Do you give us permission to communicate with you via email?* Yes No « Previous PostNext Post »
