Medical Intake Form – Internal Only

Medical History Form

"*" indicates required fields

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*

Spouse/Significant Other's Name*

Your Occupation:*

Spouse Occupation:*

Spouse / SO's Phone Number:

Spouse / SO's 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

If not in the scrotum, where?*

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

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

How old is your wife/significant other (SO)?*

Have you fathered any children?*

Yes

Has your SO ever been pregnant?*

Yes

Does your SO have any children?*

Yes

Any problems conceiving?

Yes

Has your SO had any gynecological surgeries?*

Yes

Do you and your current significant other share children?*

How old are your children? How old are your SO's children (if they are not shared)*

Elaborate on issues while conceiving:

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

Medications & Supplements

Have you ever taken testosterone supplements?*

Yes

Have you ever taken DHEA?*

Yes

Current Medications/Dosage/Purpose*

Do you 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

Have you taken steroids (prednisone) in the past year?*

Yes

Please, explain:

Have you ever had chemotherapy?*

Yes

Allergies

Please, list all medical allergies with details:*

Have you ever had a reaction to penicillin?*

Yes

Explain penicillin reaction:*

Anesthesia

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

Yes

If yes, explain:

Have you ever had a reaction to general anesthesia?*

Yes

If yes, explain:

Has anyone in your family ever had a reaction to general anesthesia?*

Yes

If yes, explain:

Lifestyle Information

Do you currently smoke?*

Yes

What do you smoke?*

Cigarettes

Cigars

Pipe

Other

Not Applicable

How much do you smoke & for how long?

When did you quit smoking?

If no, did you ever smoke?*

Yes

Do you chew tobacco?*

Yes

Do you drink alcohol?*

Yes

Do you have or did you have a drinking problem in the past?*

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?*

Yes

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

REVIEW OF THE BODY SYSTEMS

Medical History: Dental, Vision & Sleeping Patterns

False teeth or loose teeth?*

Yes

Any jaw or TMJ problems?*

Yes

Do you wear glasses or contact lenses?*

Yes

Do you use eye drops?*

Yes

Do you have Glaucoma?*

Yes

Does anyone in your family have Glaucoma?*

Yes

Are you hard of hearing?*

Yes

Do you wear a hearing aid?*

Yes

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:*

Medical History: Family History

Have you or anyone in your family had the following ailments:

Anemia?*

Yes

Bruising easily?*

Yes

Bleeding after surgery?*

Yes

Bleeding after dental work?*

Yes

Any family members bleed easily?*

Yes

Any bleeding disorders in the family?*

Yes

Have you ever had a blood transfusion?*

Yes

If yes, When/Why?*

Medical History: Cardiology

Have you or anyone in your family had the following ailments:

Heart Murmur*

Yes

Heart attack?*

Yes

Chest pain (angina)?*

Yes

Shortness of breath?*

Yes

Palpitations?*

Yes

Slow heart rate?*

Yes

High blood pressure?*

Yes

Low blood pressure?*

Yes

Stroke?*

Yes

Blood clots?*

Yes

Heart valve disease?*

Yes

Rheumatic fever?*

Yes

Do you have a pacemaker?*

Yes

Do you need antibiotics before dental work?*

Yes

If yes to above, please explain:

When was your last EKG? Was it normal or abnormal?

Medical History: Respiratory

Have you or anyone in your family had the following ailments:

Asthma?*

Yes

Chronic cough?*

Yes

Bronchitis?*

Yes

Emphysema?*

Yes

Pneumonia?*

Yes

Lung disease – breathing problems?*

Yes

If yes to above, please explain:

Medical History: Gastrointestinal

Have you or anyone in your family had the following ailments:

Stomach ulcers?*

Yes

Gastritis?*

Yes

Reflux / heartburn?*

Yes

Hiatal hernia?*

Yes

Hepatitis?*

Yes

Yellow jaundice?*

Yes

Cirrhosis or diseases of the liver?*

Yes

Trouble swallowing?*

Yes

If yes to above, please explain:

Kidney stones?*

Yes

Renal insufficiency?*

Yes

Kidney failure?*

Yes

Diabetes?*

Yes

Insulin injections?*

Yes

Thyroid problems?*

Yes

Pituitary gland problems?*

Yes

Hormone problems?*

Yes

Hormone (testosterone) replacement?*

Yes

Hormones for body building?*

Yes

Mumps?*

Yes

If yes to above, please explain:*

Medical History: Infections & Healing Patterns

Excessive scar or keloid formation?*

Yes

Slow healing?*

Yes

Repeated skin infections?*

Yes

Sensitivity to tape, ointments or latex?*

Yes

Rashes, blisters, or hives?*

Yes

Do you have any body piercings?*

Yes

Do you have any sexually transmitted diseases?*

Yes

If yes to above, please explain:

Medical History: Back / Shoulder / Neck

Back pain/injuries?*

Yes

How was it treated?

What makes it better?

What makes it worse?

Lower back problems?*

Yes

Neck pain?*

Yes

Shoulder pain?*

Yes

Knee problems?*

Yes

Hip problems?*

Yes

Arthritis?*

Yes

If yes to above, please explain:*

Medical History: Neurological

Fainting / passing out?*

Yes

Dizziness or lightheadedness?*

Yes

Seizures / epilepsy?*

Yes

Last seizure:

Medications:

Headaches?*

Yes

Migraine headache?*

Yes

Numbness or weakness in arms/hands?*

Yes

Depression?*

Yes

Manic / depressive disorder?*

Yes

If yes to above, please explain:*

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?*

Yes

If yes, please provide address.

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

Corona Virus & Zika Infection:

Have you or your sexual partner been diagnosed with a Zika Infection in the last 6 months?*

Yes

Have you or your sexual partner resided in or traveled to an area with active Zika in the past 6 months?*

Yes

Have you or any member of your immediate family been exposed or had the corona-virus/Covid19 in the last 3 months?*

Yes

Have you been vaccinated for the corona-virus/Covid19?*

Yes

When/What vaccine you received?*

Communication with the International Center for Vasectomy Reversals Office

Preferred Method of Contact*

Best time to reach you?*

Do you give us permission to communicate with you via email?*

Yes

Do we have permission to leave you voicemails?*

Yes

Emergency Contact's Name*

Emergency Contact Phone*

How did you hear about our office?

Medical Intake Form – Internal Only

Medical History Form

Contact & Personal Information

Your Vasectomy & Previous Surgeries

Fertility History

Medications & Supplements

Allergies

Anesthesia

Lifestyle Information

REVIEW OF THE BODY SYSTEMS

Medical History: Dental, Vision & Sleeping Patterns

Medical History: Family History

Medical History: Cardiology

Medical History: Respiratory

Medical History: Gastrointestinal

Medical History: Infections & Healing Patterns

Medical History: Back / Shoulder / Neck

Medical History: Neurological

Your Primary Care Provider:

Corona Virus & Zika Infection:

Communication with the International Center for Vasectomy Reversals Office

ADDRESS

CALL

SOCIAL

Medical History Form

Contact & Personal Information

Your Vasectomy & Previous Surgeries

Fertility History

Medications & Supplements

Allergies

Anesthesia

Lifestyle Information

REVIEW OF THE BODY SYSTEMS

Medical History: Dental, Vision & Sleeping Patterns

Medical History: Family History

Medical History: Cardiology

Medical History: Respiratory

Medical History: Gastrointestinal

Medical History: Infections & Healing Patterns

Medical History: Back / Shoulder / Neck

Medical History: Neurological

Your Primary Care Provider:

Corona Virus & Zika Infection:

Communication with the International Center for Vasectomy Reversals Office

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ADDRESS

CALL

SOCIAL