18)
Have you ever had:
(Undescended testis / Surgery to bring down
testicle / Surgery for hernia / Surgery for
prostate enlargement / Surgery for torsion of
testicle / Hypospadias (urethral opening on
the underside of the penis) / Accident involving
your genitalia / Discharge needing treatment/
Diagnosed sexually transmitted disease / Inflammation
of testicle or epidydimis / Mumps (as an adult
/ Cystoscopy / Scrotal surgery (surgery to your
testicule) / Vasectomy / Previous radiotherapy
/ Previous chemotherapy) |
yes
, no
Please give details:
|
| 19)
Do you have any children from previous relations? |
yes
, no
|
| 19a
) If yes to above question, how many children? |
|
| 20)
Do you have any problems with sexual intercourse? |
yes
, no
|
| 21)
Previous infertility investigations and treatment? |
yes
, no
|
| 21a)
If yes to above question, what type of investigations/treatments? |
|
| 22)
Have you had any serious illness in the past? |
yes
, no
If yes, please give details:
|
| 23)
Are you on any long term medications? |
yes
, no
If yes, please give names and dosages:
|
| 24)
Do you have any conditions which run in your
family? (example - Sickle Cell...) |
yes
, no
If yes, please give details:
|
| 25)
Do you have any allergies? |
yes
, no
If yes, please give details:
|
| 26)
How many cigarettes do you smoke per day? (enter
0 if non-smoker) |
|
| 27)
How many glasses of alcohol do you drink per
day? |
|
| |
| Female
Partner |
| Menstrual
History: |
|
| 28)
What is your height? |
|
| 29)
What is your weight? |
|
30)
How often do your periods come?
(example - average 28 days / range 26-35) |
average
/
range
|
| 31)
How many days does your period last? |
|
| 32)
Are your periods painful? |
|
| 33)
Have your periods ever stopped (excluding pregnancy)? |
yes
, no
|
| |
|
| Previous
Pregnancies: |
|
| 34)
How many live birth(s)? |
|
| 35)
Year and outcome for question 34 (for present
partner). |
|
| 36)
Year and outcome for question 34 (previous partner(s).
|
|
| |
|
| Gynecological
History: |
|
| 37)
Have you had an history of STD, PID, surgery
of your tube, LEEP, laparoscopy, hysteroscopy,
surgery of your cervix? |
yes
, no
|
| 38)
Any other abdominal/pelvic operations? |
Please
give details
|
| |
|
| Sexual
History: |
|
| 39)
On average, how often do you have sexual intercourse? |
per week |
| |
|
| General
Health: |
|
| 40)
Is your weight stable/ increasing / decreasing? |
Please
give details
|
| 41)
Have you ever had any serious illness in the
past? |
Please
give details
|
| 42)
Have you ever had a discharge from your nipples? |
yes
, no
|
43)
Do you have a problem with body hair?
(example - facial hair) |
yes
, no
|
| 44)
Do you have any conditions which run in your
family? (example - Sickle Cell) |
yes
, no
If yes, please give details
|
| 45)
Are you on any long term or current medications? |
yes
, no
If yes, please give names and dosage
|
| 46)
Do you have any allergies? |
yes
, no
If yes, please give details
|
| 47)
How many cigarettes do you smoke per day? (enter
0 if non-smoker) |
|
| 48)
How many glasses of alcohol do you drink per
day? |
|
| |
|
| Infertility
History: |
|
| 49)
How many years have you been trying to conceive
as a couple? |
|
| 50)
Any previous infertility investigations? |
yes
, no
If yes, please give details
|
| 51)
Have you ever had ovulation induction with or
without intrauterine insemination? |
yes
, no
If yes, please give details
|
| 52)
Have you ever had In Vitro Fertilization (test
tube treatment), GIFT (gamete intra-fallopian
tube transfer) or ZIFT (zygote intra-fallopian
tube transfer)? |
yes
, no
If yes, please give details
|
| |
|
