Medical Intake Form – Internal Only

Dads Again Medical History Form

This medical history form will help us provide the best care and recommendations leading up to, during, and after your vasectomy reversal.

"*" indicates required fields

Company

This field is for validation purposes and should be left unchanged.

Contact & Personal Information

Name*

Date of Birth:*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Cell Phone Number*

Email*

Height*

Weight*

How would you describe your general health:*

Excellent

Good

Fair

Poor

Marital Status*

Partner Name*

Your Occupation:*

Partner Occupation:*

Partner's Phone Number*

Partner Email:*

Your Vasectomy & Previous Surgeries

Date of Your Vasectomy:*

Was the incision made in the scrotum?*

Yes

Not Sure

Vasectomy Details*

One Incision

Two Incisions

Clips

Ties

Cautery

I don't know

If not in the scrotum, where?*

Did you have any problems/complications with your vasectomy?*

Have you ever had a sperm retrieval? If so, when was it and was sperm found at the time of the retrieval?

Did you have a hernia or other scrotal/groin surgery done at the same time?*

Yes

Not Sure

Elaborate on dual surgery purpose:

List all surgeries, including hernias, and approximate year/location of surgery*

Fertility History

Do you or your partner have children?*

Please, elaborate in more detail (Do you share children? How old are they?)

How old is your partner?*

Have you or your partner had any issues while conceiving?

Is there any other information about you or your partner's fertility health, which you feel we should know?*

Medications & Supplements

Have you ever taken testosterone or body building androgens?*

Yes

Are you currently taking testosterone?*

Yes

If you are not currently on testosterone or androgens, when did you stop?*

Are you currently taking any medications? Please list the medication and dosage or NA if not applicable*

Do you regularly take aspirin?*

Yes

Did a doctor put you on aspirin?*

Yes

Not Applicable

Last Date Taken

When/For what reason?

Check any/all anti-inflammatory medications that you are currently taking*

Ibuprofen

Advil

Motrin

Nuprin

Aleve

Naprosyn

Other

Last dose taken/for what reason

Do you regularly take aspirin?*

Yes

Have you taken steroids (prednisone) in the past? If so, explain:*

Do you have any body piercings?

Allergies

Please, list all medical allergies with details:*

Have you ever had a reaction to antibiotics? If so, please explain:*

Anesthesia

Have you ever had a reaction to local anesthesia (Xylocaine, lidocaine, Marcaine)?*

Yes

If yes, explain:

Lifestyle Information

Do you currently smoke?*

Yes

What do you smoke?*

Cigarettes

Chewing Tobacco

Cigars

Marijuana

Not Applicable

How much do you smoke on a daily basis? How long have you been smoking?

Do you use cannabis?*

Yes

Do you drink alcohol?*

Yes

What do you drink?

How often/much do you drink?

Do you drink a lot of coffee, tea, Coke/Pepsi, Mountain Dew (high caffeine drinks)?*

Yes

If you stop consuming caffeine, do you get a headache within a few hours?*

Yes

What strenuous activities do you take part in on a daily, weekly, monthly basis?*

REVIEW OF THE BODY SYSTEMS

Difficulty breathing at night?*

Yes

Do you snore (you should ask your wife)?*

Yes

Do you have sleep apnea?

Yes

Do you use a CPAP machine?

Yes

Information about your vision, dental, and sleeping patterns we should know:*

Do you have any issues with bleeding after surgery or dental work? Do you have any bleeding disorders in the family? If so, please explain:*

Information about your cardiac health (heart attacks, heart murmur, high blood pressure, low blood pressure, stroke, blood clots, heart valve disease, pacemaker) we should know:

If you have had an EKG in the last 5 years, was it normal or abnormal?

Do you have any breathing issues such as asthma or lung disease? If so, please explain:

Do you currently have or have you ever had: Stomach Ulcers, Reflux/Heartburn, Hiatal Hernia, Hepatitis, Liver Disease or Cirrhosis of the Liver? If so, please explain:

Do you have any kidney issues? Diabetes? Insulin injections? Thyroid problems? Hormone problems? Mumps? If so, please explain:

Do you have issues with excessive scaring or keloid formation? If so, please explain:

Information about your neurological health we should know (seizures, epilepsy, headaches/migraines, fainting/passing out, vertigo):

Your Primary Care Provider:

Who is your primary doctor?*

When was the last time you saw him/her?*

Would you like us to send him/her a copy of your records?*

If so, you will be provided your medical records directly, which you can then provide to your primary care physician. If you would like for us to send your records directly to your primary care, you will be required to sign a medical records release consent via Docusign from our office.

Yes

If yes, please provide address.

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Communication with the International Center for Vasectomy Reversals Office

Preferred Method of Contact*

Best time to reach you?*

Do we have permission to contact you by phone and email?*

Yes

Do we have permission to leave you voicemails?*

Yes

Do you give us permission to communicate with you via text?

By submitting this form and allowing text messages, you consent to receive payment links, notifications and reminder text messages from International Center for Vasectomy Reversals. Your personal information is private, protected by HIPAA and will never be sold to a third party. Consent is not a condition of purchase. Msg & data rates may apply. Msg frequency varies. Unsubscribe at any time by replying STOP. Reply HELP for help.

Yes

Emergency Contact's Name*

Emergency Contact Phone*

How did you hear about our office?

CAPTCHA

Medical Intake Form – Internal Only

Dads Again Medical History Form

Contact & Personal Information

Your Vasectomy & Previous Surgeries

Fertility History

Medications & Supplements

Allergies

Anesthesia

Lifestyle Information

REVIEW OF THE BODY SYSTEMS

Your Primary Care Provider:

Communication with the International Center for Vasectomy Reversals Office

ADDRESS

CONTACT

SOCIAL

Dads Again Medical History Form

Contact & Personal Information

Your Vasectomy & Previous Surgeries

Fertility History

Medications & Supplements

Allergies

Anesthesia

Lifestyle Information

REVIEW OF THE BODY SYSTEMS

Your Primary Care Provider:

Communication with the International Center for Vasectomy Reversals Office

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ADDRESS

CONTACT

SOCIAL