-Age:___
-Prior paternity?:___
-Coital frequency:_____
-Sexual dysfunction?: No
-Duration of infertility:____
-Any previous infertility evaluation and treatment? (if so, results): None
-PMH (past and current):____
-Episodes of STIs:_____
-PSH: No hx of GU or inguinal surgery.
-Last Pap Smear (date & results):_____
-SH: Denies tobacco, alcohol, illicit drugs use (marijuana, cocaine, etc). Denies environmental exposures like lead and arsenic. No external factors like biking, hot tubs/saunas.
-FH: Denies a family history of infertility, birth defects, CF, genetic mutations, mental retardation.
-Pertinent negatives: Patient denies symptoms of thyroid disease. He also denies a history of STIs, XRT / chemo. No history of mumps, testicular trauma/torsion, and undescended testicles. Patient denies a history of meds like sulfasalazine, cimetidine, nitrofurantoin.
Patient denies diabtes (which may lead to low sperm count 2/2 to retrograde ejaculation).
-Current medications (including herbal/OTC/Vitamins):____
-Allergies to meds:____
