Male Fertility & Andrology Intake Form
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Male Fertility & Andrology Intake Form
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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.
What's included
- Reproductive history and infertility duration documentation
- Semen analysis and hormonal testing result tracking
- Sexual health and genitourinary condition screening
- Prior fertility treatment and surgery history
- Occupational and lifestyle exposure assessment
- HIPAA consent with e-signature capture
- Structured medication list with dosage and frequency tracking
- Insurance information collection with carrier and policy details
Who uses this template
- Reproductive urology and andrology practices
- Male fertility evaluation within IVF centers
- Testosterone and hormonal health optimization clinics
- Pre-vasectomy reversal and sperm retrieval consultations
All form fields
16 fields across 3 pages. Customize any field after signing up.
How to use the Male Fertility & Andrology Intake Form
Getting started with this template takes just a few minutes. Sign up for a free Formisoft trial, then select the Male Fertility & Andrology Intake Form from the template library. The form is ready to use immediately, but you can customize every field, add your practice logo, and adjust the layout to match your workflow.
Setup steps
- 1Choose the template. Find the Male Fertility & Andrology Intake Form in the template library and click “Use this template” to add it to your account.
- 2Customize fields. Add, remove, or reorder any of the 16 fields. Set fields as required or optional based on your practice needs.
- 3Brand it. Upload your logo, pick your colors, and add a custom welcome message so patients see your practice identity.
- 4Share with patients. Send the form via SMS, email, or embed it on your website. Patients complete it on any device before their visit.
- 5Review submissions. Responses appear in your dashboard in real time. Patient records are created automatically from the data collected.
Frequently asked questions
Is the Male Fertility & Andrology Intake Form HIPAA compliant?
Yes. All Formisoft templates, including the Male Fertility & Andrology Intake Form, are HIPAA compliant. Data is encrypted with 256-bit AES at rest and TLS 1.3 in transit. A Business Associate Agreement (BAA) is included on every plan.
Can I customize the fields in this template?
Absolutely. You can add, remove, reorder, or modify any of the 16 fields. You can also add conditional logic, new pages, file uploads, e-signatures, and payment fields.
How do patients fill out this form?
Patients receive a link via SMS, email, or QR code. They complete the form on their phone, tablet, or computer before their appointment. No app download required.
Can I send this form automatically before appointments?
Yes. Formisoft's workflow automation can send intake forms automatically when an appointment is booked. You can set the timing (e.g., 48 hours before the visit) and include reminders for patients who haven't completed it.
Does this template work on mobile devices?
Yes. The Male Fertility & Andrology Intake Form is fully responsive and works on any device. Most patients complete intake forms on their phone, so every template is optimized for mobile-first use.
Start with this template
Sign up and start customizing the Male Fertility & Andrology Intake Form for your practice. Set up in minutes.
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