Male Fertility Intake Form

This form does need to be filled out before your first appointment regardless of whether or not you are an existing patient.

PLEASE NOTE: If we were to go through these questions with you in person, it would take around 30 minutes. After that, we go through further tests (such as pulse, face, palm, ear, tongue diagnosis or thermal scan) followed by a discussion of the findings and recommended treatment plan.

By filling this form, you save around 30 minutes of our time which we would otherwise need to charge you for, resulting in significant savings to you. That is why we created this detailed form; all the questions on this form are questions we would otherwise ask in the initial exam. Now you can answer all these online without any cost.  After that your in person exam will just take 30 minutes and cost only $40.

If you have any trouble with the form, please call reception on 07 846 7956 or reply to this email for assistance. Thank you for your patience.

 

1. Mobile Phone Number: (this is what we will use to identify this form as yours, so please make sure you write the same number that you give us over the phone or through our online sign up form.)

1.1 Initials of first and last name

2. Occupation

3. Do you work for an ACC accredited employer? (if "Yes" go to "4", if "No" go to "5")

4. What is your employer’s name?

5. How did you hear about us?*

6. Name of person who referred you if your answer above is "Word of Mouth" or "GP/specialist referral" or "Other".

7. Main Complaint

8. What is the main complaint you are seeking help for at Centre of Balance?

9. When did it begin?

10. Has this problem(s) been medically diagnosed?

11. If yes, what was the diagnosis?

12. What have you done to try to help with this?

13. Have you received any acupuncture treatments for this condition(s) previously?

14. What kind of exercise do you do, if any, and how often?

15. How many cups of soda/fizzy drink do you drink per day?

16. How many cups of alcohol do you drink per day?

17. How many cups of coffee do you drink per day?

18. How many cups of water do you drink per day?

19. Do you smoke?  If yes, how often?

20. Do you use a hot tub? If yes, how often?

21. Are you regularly exposed to second hand smoke?

22. Do you use (or have you used) recreational drugs? If yes, please list which kinds and how often.

23. How old is your home?

24. How long have you lived there for?

25. Do you live near any of the following?

26. Have you done any recent renovations to your home? If yes, please describe (e.g. painting, new carpets etc.)

27. Do you have any household pets? If yes, what type of pet?

28. Are you allergic to any medications that you know of?

29. Please list any medications that you react to and what reaction you have:

30. Please list any medications you currently take, and what you take them for:

31. Do you have a history of any of the following conditions?

32. If "other" please describe (you can also elaborate on any conditions you may have):

33. Have you initiated any pregnancies in the past?

34. If yes, how many pregnancies?

35. Number of pregnancies with current partner?

36. When was the most recent pregnancy?

37. Have you ever had a semen analysis?

38. If yes, when?

39. Please provide the following results of the analysis.  Volume (million cell/ml):

40. Motility (%):

41. Morphology (% normal forms):

42. Agglutination (clumping):

43. Progress Motility:

44. Have you had a prostate check?

45. PSA levels and date checked:

46. Do you have an erection when you wake up in the morning?

47. Do you ejaculate quickly during sex?

48. Do you have difficulty ejaculating during sex?

49. Do you have difficulty reaching an orgasm?

50. Are you able to bring your partner to orgasm?

51. How many times per week do you ejaculate?

52. How many times do you have sex with your partner per week?

53. How many times can you have sex in a day without feeling tired?

54. Have you ever had any of the following tests or procedures?

55. Please give the date, result and any comments on each test you have had.

56. Please give details of your surgical history. (Procedure, date, reason, outcome).

57. Is there a history of any of the following conditions in your family?

58. If you answered yes to any of the previous questions or if there is a history of any other illness in your family, please elaborate. (i.e. mother's side, father's side etc.)

59. Please tick the questions you have experienced symptoms for in the last 6 months. (Blood Deficiency symptoms):

60. Please tick the questions you have experienced symptoms for in the last 6 months. (Spleen Qi Deficiency)

61. Please tick the questions you have experienced symptoms for in the last 6 months. (Kidney Yang Deficiency)

62. Please tick the questions you have experienced symptoms for in the last 6 months. (Kidney Yin Deficiency)

63. Please tick the questions you have experienced symptoms for in the last 6 months. (Blood Stasis)

64. Please tick the questions you have experienced symptoms for in the last 6 months. (Liver Qi Stagnation)

65. Please tick the questions you have experienced symptoms for in the last 6 months. (Heart Deficiency)

66. Please tick the questions you have experienced symptoms for in the last 6 months. (Excess Heat)

67. Please tick the questions you have experienced symptoms for in the last 6 months. (Dampness)

68. Is there anything else you would like to add that you feel is important and has not been covered?