Male Fertility & Andrology Intake Form

The Male Fertility & Andrology Intake Form is purpose-built for reproductive urology and andrology practices, capturing the detailed male reproductive history that fertility specialists need for comprehensive evaluation and treatment planning. This template collects patient demographics alongside a thorough reproductive assessment including duration of infertility, partner reproductive history, prior semen analysis results, sexual health and function (libido, erectile function, ejaculatory function), history of genitourinary conditions (varicocele, cryptorchidism, testicular torsion, infections), prior reproductive surgeries, and hormonal symptom screening.

Designed for reproductive urology practices, andrology laboratories, male fertility clinics, and IVF centers with male factor evaluation services, this form includes sections for hormonal testing history (testosterone, FSH, LH, prolactin, estradiol), genetic testing results (karyotype, Y-chromosome microdeletion, CFTR mutation analysis), prior fertility treatments (varicocelectomy, TESE/micro-TESE, sperm cryopreservation, intrauterine insemination, IVF/ICSI), medication history including testosterone replacement therapy and its impact on spermatogenesis, occupational and environmental exposures (heat, chemicals, radiation), and lifestyle factors affecting fertility (smoking, alcohol, recreational drugs, BMI, exercise habits).

All fields are HIPAA-compliant and optimized for the male fertility evaluation workflow. The pre-visit form allows patients to compile their reproductive history, previous test results, and treatment records from other providers before the consultation. This is particularly valuable in male infertility where patients often present after initial evaluation by a gynecologist or reproductive endocrinologist and arrive with partial records that need to be systematically organized for the andrologist.