Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Male Fertility & Andrology Intake Form
Your information
Full Name *
Date of Birth
____ / ____ / ________
Phone Number
Email Address
Duration of Infertility
Partner Reproductive History
Please bring to your visit: prior semen analysis results
Sexual Health Assessment
Additional details
Genitourinary History
Hormonal Testing History
Prior Fertility Treatments
Current Medications
| Medication | Dose | How often |
|---|---|---|
Occupational Exposures
Lifestyle & Habits
Insurance Information
Carrier
Member ID
Group number
Subscriber name
Consent & Signature
Date
Male Fertility & Andrology Intake Form template from formisoft.com. formisoft.com/intake-templates/male-fertility-intake