Pre-Semen Analysis Assessment Form

1. Are you currently trying to conceive?

2. How long have you been trying to conceive?

3. Have you fathered any pregnancies previously?

4. Has your partner ever been pregnant?

5. Has your partner undergone fertility evaluation?

6. Have you or your partner experienced:

7. Have you undergone previous fertility treatment?

1. Have you previously had a semen analysis?

2. Were any abnormalities identified?

3. Have you ever had a sperm DNA fragmentation test?

4. Do you experience:

5. Frequency of intercourse during fertile period

Have you ever been diagnosed with:

Reproductive-related conditions:

Have you undergone:

Current fertility supplements

Use of:

Do you have regular exposure to:

Please indicate if any apply:

Have you experienced:

Family history of:

Any difficulty producing a semen sample?