(091) 530054
info@GalwayBayMedicalCentre.ie

Fertility Clinic – PreConsult Questionnaire Male

Personal Details

DD slash MM slash YYYY

Medical History

Have you been diagnosed with any medical conditions?(Required)
Are there any significant medical or genetic issues in your family?(Required)
Do you have of the following Urological conditions?(Required) Tick all that apply
Do you have any medical issues or symptoms at present?(Required)

Lifestyle

Do you smoke cigarettes or vape?(Required)
Do you drink alcohol?(Required)
Have you taken recreational drugs in the last year?(Required)
Do you ever feel stressed, anxious or depressed?
Is your bodyweight in the healthy range?(Required)
Do you have a healthy diet?(Required)
Do you get plenty of exercise?(Required)
Have you ever conceived with either your current or a previous partner?(Required)

Sexual History

Have you had any sexually transmitted infections in the past?(Required)
Do you get discomfort or other difficulties with sex?
Do you have sex often enough to conceive (every 2-3 days)
Do you use lubrication? Can cause sperm trapping…
Is a delay in becoming pregnant causing you stress
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