Welcome to UCSF Male Reproductive Health Practice at the Center for Reproductive Health

To prepare for your initial consultation there are three things you need to do:

1. Complete the new patient questionnaire and bring with you on the day of your appointment. Please arrive 15-20 minutes before your scheduled visit to complete all pre-visit paperwork and check-in. 2. Bring your insurance card and photo ID 3. Call your insurance company* to verify coverage. Fertility treatment often has limited coverage. Payment for services rendered at our clinic is required at the time of visit. We accept: cash (in exact amounts only; the front desk cannot make change), personal checks, VISA, MasterCard, American Express and Discover.

We are located at 2356 Sutter on the 3rd floor of the Women’s Health Center. Additional detail can be found at: http://mountzion.ucsfmedicalcenter.org/map.html If you need to cancel or reschedule your appointment, please call (415) 353-7131 at least 48 hours in advance.

Thank you for choosing the UCSF Male Reproductive Health Practice at the Center for Reproductive Health.

* For Patients with HMO Insurance coverage: In order to use your benefits, you will need to obtain AUTHORIZATION from your PCP (primary care physician). Authorizations must be in place prior to your visit. We do not accept retroactive authorizations. If you do not have this authorization at the time of visit, you will be responsible for full payment; a referral is not an authorization. ** Due to the sensitive nature of our practice, we ask that you not bring children to our office. 2356 Sutter Street, 3rd Floor San Francisco, CA 94115 www.ucsfivf.org

P#: 415.353.7131 F#: 415.885-3663 www.ucsfhealth.org

UCSF Center for Reproductive Health Men’s Health Questionnaire Patient name: Street address: City: State: Country: Telephone:

E-mail: Date of birth: Partner’s name Partner’s birthdate:

Zip:

County (e.g. Alameda):

Home: Cell: Work: /

/

Age:

/

/

Age:

Primary MD Name: Who referred you to the Center for Reproductive Health? Physician: Insurance company UCSF website Former patient / friend Self Reason(s) for Visit: Fertility consultation Vasectomy reversal consultation Vasectomy consultation Difficulty with erections Peyronie’s disease Other (please describe):

Phone: (

)

-

Phone: (

)

-

Ejaculation problems (e.g. rapid or delayed) Low testosterone / low sex drive Urination problems (e.g. slow stream, urgency) Testicle or groin pain Blood in the urine

Marital Status: Married Years married: Domestic partnership Years together: Single What is your racial and ethnic background? (Check all that apply) African American/Black Latino / Hispanic American Indian or Alaskan Native Middle – Eastern Asian Native Hawaiian or Pacific Islander Caucasian / White Other: Work Status: Employed full-time Student Employed part-time Unemployed Self-employed Disabled Retired Other: Place of Employment: Job Title: v.91312

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Do you have any allergies to medications? Medication: Medication: Medication: Preferred Pharmacy: Phone: Current Medications

None: Reaction: Reaction: Reaction:

Address:

Name

Dose

Frequency

1 2 3 4 5 6 7 8 9 10

Date Started / / / / / / / / / / / / / / / / / / / /

Past Medical History: Please select any illnesses that you may have/had. How would you rate your overall health? Anemia Asthma Bladder stones Bleeding disorder Blood in semen Bowel problems Bronchitis Cancer (Type?): Cystic fibrosis Depression Diabetes Emphysema/COPD Epididymitis Epilepsy/Seizures Fever (>101F) in last 3months Genetic Condition Describe: GERD/frequent indigestion Hay fever Heart problems High blood pressure High cholesterol or triglycerides

Poor

Average

Good

Excellent

Immune disorder Kidney disease Kidney stones Liver disease Multiple sclerosis Mumps Peyronie’s disease Prostatitis Sexually transmitted infection Sickle cell anemia/trait Spinal cord injury Stroke Orchitis/Testicular infection Testicle(s) undescended at birth Testicular injury requiring hospitalization or surgery Thyroid disease Tuberculosis (TB) Urethritis Urinary tract infection Vascular disease Other:

Past Surgical History: Have you had any of the following surgeries? Inguinal hernia repair Varicocele surgery or embolization Undescended testicle surgery Cyst removal: testicular or scrotal v.91312

Left Left Left Left 2

Right Right Right Right

Both Both Both Both

/ / / /

DATE / / / /

Past Surgical History: Have you had any of the following surgeries? Vasectomy Vasectomy reversal Pelvic surgery Back surgery Penile prosthesis Prostate surgery for urinary blockage (e.g. TURP, laser prostate surgery) Radiation with/without hormone treatment (Lupron) for prostate cancer Prostate removed for cancer (i.e. prostatectomy) Transplant: Which organ(s)?: Bladder removed for cancer (i.e. cystectomy) Other (please describe):

/ / / / / / / / / / /

DATE / / / / / / / / / / /

Family History: Briefly list any health issues Mother: Father: Grandparents: Maternal aunt: Maternal uncle: Paternal aunt: Paternal uncle: Brother: Sister:

Social History: Tobacco Use:

# Years Used

Current every day smoker Current some day smoker Former smoker Non-smoker, exposed to smoke at home Never smoker

Smokeless Tobacco:

/

/

/

/

Cigarettes Cigars Pipe

# Years Used

Current user Former user Never used

Amount /day: Date quit:

Alcohol Use:

# of alcohol drinks/week:

No Yes

Cans of beer Drinks containing 0.5 oz of alcohol Glasses of wine Shots of liquor

Drug Use:

No

Yes

In the past

Anabolic steroids Benzodiazepines Cocaine LSD

Sexual Activity Not currently No Yes v.91312

Tobacco Type:

Packs/day: Packs/day: Date quit:

No Marijuana Methamphetamines Opiates Other:

Partners Female Male Both female and male 3

Yes

In the past

Review of Systems: Do you have any problems or symptoms in the following areas? General

Psychiatric

Recent weight gain Recent weight loss Recurrent fevers, chills, sweats Fatigue

Eyes Glasses, contact lenses Blurred or double vision Glaucoma

Ear/Nose/Throat Ringing in the ears Bleeding gums

Genitourinary

Nervousness / anxiety Depression Insomnia

Skin Changing moles Skin cancer

Muscles and Joints Joint stiffness or pain Muscle pain or cramping Weakness of muscles or joints Back pain

Allergic Immunologic

Blood in the urine

Respiratory Asthma/wheezing Chronic cough Frequent sinus infections

Heart Problems Heart attack Chest pain or angina Palpitations Swelling of feet, ankle, or hands

Gastrointestinal

Low resistance to infection Recent cold or flu Environmental allergies

Hematologic Easy bruising Enlarged lymph nodes Blood clots in legs or lungs

Neurologic Numbness or tingling sensations

Convulsions or seizures Worsening memory/concentration

Decreased appetite Severe heartburn Varicose veins Constipation

Endocrine: Difficulty smelling? Severe headaches? Tunnel vision?

Reproductive History: Do you have any children with your current partner? Have you had children with any previous partners? When did you stop using birth control? (mm/dd/yyyy) When did you begin trying to get pregnant? (mm/dd/yyyy) Are you timing intercourse with your partner’s cycles? For how many months have you timed intercourse? What fertility treatments have you used? (Select all that apply) Clomid or medication for you Clomid or medication for your partner Vasectomy reversal Varicocele surgery or embolization

Yes Yes

No No

/ / Yes, monthly

How many? How many? / / Yes, occasionally

N/A N/A No # Cycles

IUI: How many cycles? IVF: How many cycles? IVF / ICSI: How many cycles? Other:

What form of birth control do you use currently or have you used most recently? None Condom Birth control pills IUD If you have any children, please list their ages and gender:

Diaphragm Rhythm (i.e. time intercourse to partner cycles) Withdrawal (i.e. remove penis before ejaculation) Other: Age

Child #1 Child #2 Child #3 Child #4

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Male

Female

Is stress at work a significant problem? No, no significant stress Yes, stress is a small problem Have you had exposure to any of the following:

Yes, stress is a moderate problem Yes, stress is a big problem Never Yes, currently

Yes, in past

Chemicals or pesticides used to kill insects, rodents, or weeds? Radiation for treatment of cancer? Chemotherapy for treatment of cancer? Industrial solvents or dyes? Excessive heat in your work or hobbies?

Did your parents have difficulty conceiving or maintaining/carrying a pregnancy? Did your siblings have difficulty conceiving or maintaining/carrying a pregnancy? In the past three months, HOW OFTEN did you use hot tubs, saunas, or Jacuzzis? Never Less than once per month

A few times each month Several days each week

Yes Yes

No No

Every day

No current partner (skip partner history section)

Partner Fertility History

What is your partner's weight without shoes (lbs)? What is your partner's height? Are your partner's menstrual cycles regular? Yes No On average, how many days are there from the first day of one menstrual cycle to the first day of the next? What is the total number of pregnancies, children, and # Pregnancies # Children miscarriages your partner has had? Has your partner had a fertility evaluation? Yes No Did she have a normal HSG (hysterosalpinogram)? Yes No What was her antral follicle count (AFC)? After her fertility evaluation, was your partner diagnosed with any of the following? None, no partner infertility problems found Endometriosis Polycystic ovary syndrome (PCOS) Irregular ovulation Blocked fallopian tubes

I don’t know

# Miscarriages I don’t know I don’t know I don’t know

Fibroids Hypothalamic or pituitary problem Premature ovarian failure Diminished ovarian reserve Other (please specify)

Sexual History How would you rate your libido (sex drive, Terrible Poor Average Good Excellent interest in sex)? How strong are your Extremely Neither weak Extremely Weak Strong erections? weak nor strong Strong When did your difficulties with erections begin? (mm/dd/yyyy) / / What do you think caused your erection problems? On average, how many times do you have 0 1-2 3-4 5-6 7+ intercourse in a typical week? Which medications or treatments have you tried to improve your erections? (Select all that apply) Intraurethral suppository (“MUSE”) Penile injections Penile prosthesis Other:

None Herbal therapies, Chinese medicine Oral medications (e.g. Viagra, Cialis, Levitra) Vacuum erection device

Do you use any of the following lubricants for intercourse? (Select all that apply) Preseed KY jelly (or other commercial lubricant)

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Mineral oil Egg whites

5

Olive oil or other vegetable oil Other:

Some people have sexual relationships with men, some with Women and women, and some with both. Have you had sexual Women only Men relationships with: Straight, Gay, How do you identify yourself? Bisexual heterosexual homosexual Over the past six months, considering your general experiences with sex, how No Somewhat Moderately Very distressed have you been by these distress distressed distressed distressed experiences? How many hours per week do you ride a 0 1-2 3-4 5-6 bicycle? While riding your bike, how often do you experience numbness in your groin or penis?

Less than ½ the time

Never

½ the time

Men only Other Extremely distressed 7+

More than ½ the time

Every time

Sexual Health Inventory for Men (SHIM) Over the past 4 weeks…

How often were you able to get an erection during sexual activity? When you had erections with sexual stimulation, how often were your erections hard enough for penetration? During sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner? When you attempted sexual intercourse, how often was it satisfactory for you?

During sexual intercourse, how difficult was it for you to maintain your erection to completion of intercourse?

How did you rate your confidence that you could get and keep an erection? SHIM Total:

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Almost never / never

A few times (much less than ½ the time)

Sometimes (about ½ the time)

Most times (much more than ½ the time)

Almost always / always

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

Extremely difficult

Very difficult

Difficult

Slightly difficult

Not difficult

1

2

3

4

5

Very low

Low

Moderate

High

Very high

1

2

3

4

5

6

The following questions refer to your general experience with intercourse. Circle the appropriate answer. On average, how long does intercourse last form the time your penis enters your partner to the < 1 minute 1-5 minutes 5-10 minutes 10+ minutes time you ejaculate? Not difficult at Somewhat Moderately Very difficult Extremely all difficult difficult difficult How difficult is it for you to delay 1 2 3 4 5 ejaculation? Almost never Less than ½ More than ½ Almost always ½ the time or never the time the time or always Do you ejaculate before you want to? 1 2 3 4 5 Do you ejaculate with very little 1 2 3 4 5 stimulation? Not at all Slightly Moderately Very Extremely frustrated frustrated frustrated frustrated frustrated Do you feel frustrated because of 1 2 3 4 5 ejaculating before you wanted to? Not at all Slightly Moderately Very Extremely concerned concerned concerned concerned concerned How concerned are you that your time to ejaculation leaves your partner 1 2 3 4 5 sexually unfulfilled? PEDT Total:

Urinary History Circle 1 number on each line Over the past month or so, how often have you had a sensation of not emptying your bladder completely after you finished urinating? During the past month or so, how often have you had to urinate again less than two hours after you finished urinating? During the past month or so, how often have you found you stopped and started again several times when you urinated? During the past month or so, how often have you found it difficult to postpone urination? During the past month or so, how often have you had a weak urinary stream? During the past month or so, how often have you had to push or strain to begin urination? Over the past month, how many times per night did you most typically get up to urinate from the time you went to bed at night until the time you got up in the morning?

Not at all

Less than 1 time in 5

Less than ½ the time

About ½ the time

More than ½ the time

Almost always

0

1

2

3

4

5

0

1

2

3

4

5

0

1

2

3

4

5

0

1

2

3

4

5

0

1

2

3

4

5

0

1

2

3

4

5

None

1 time

2 times

3 times

4 times

5+ times

0

1

2

3

4

5

Mostly dissatisfied

Unhappy

AUASS Total:

Delighted

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Pleased

7

Mostly satisfied

Mixed

Terrible

How would you feel if you had to live with your urinary condition the way it is now, no better, no worse, for the rest of your life?

1

0

2

3

4

5

6

No pain, skip this section

Pain History When did your pain begin (mm/dd/yy)?

/

/

Please mark the location(s) of your pain on the diagram. What do you think caused your pain?

Using the scale below, how intense is the pain at its worst? Over the past 4 weeks, how intense is the pain on average?

How would you describe your pain? (Select all that apply) □

Sharp (like a knife)

□

Ache (like a tooth)

□

Pulling or pressure

□

Burning

□

Shooting

□

Comes and goes

□

Throbbing

□

Pinching

□

Constant, with me all the time

What makes the pain worse? What makes the pain get better? Have you tried any of the following medications or treatments for your pain? □ Anti-inflammatory medications (e.g. ibuprofen, naproxen) □ Narcotic pain medication (e.g. codeine, vicodin, hydrocodone) □ Anti-depressant medication (e.g. paxil, celexa, nortriptyline)

□ Antibiotics (e.g. ciprofloxacin, doxycycline) □ Gabapentin/Neurontin

□ Acupuncture, Chinese medicine, naturopathic medicine □ Spermatic cord block

□ Physical therapy

□ Spinal block

□ Other:

Have you had a scrotal ultrasound?

□

□

Yes

What did this show?

v.91312

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No