Male mandatory questionnaire

Gender(Required)

Please enter the gender you describe yourself as

Pronouns(Required)

Please enter the pronouns you prefer e.g. he/him, they/them

If you need an interpreter, which language?(Required)

Where were you born?(Required)

When did you move to the UK?(Required)

What is your job?(Required)

How long have you been in your current relationship?

Please tell us the number of years

How long have you been trying for a pregnancy?(Required)

Please tell us the number of years and months

How old are you on the day you are completing this questionnaire?(Required)

Please enter your age

What is your weight?(Required)

Please enter your weight in Kg

What is your height?(Required)

Please enter your height in metres

Section B – Partner Details

Partner's first name(Required)

Partner's last name(Required)

Section C – Previous Pregnancies

How many pregnancies have you fathered?(Required)

Which years were they?(Required)

Were they with your current partner or a previous partner?(Required)

Were they natural pregnancies or following fertility treatment?(Required)

What was the outcome of your pregnancies?(Required)

Please enter your pregnancy outcomes e.g. child born, miscarriage, termination

Operation details(Required)

Hernia repair details(Required)

Vasectomy details(Required)

Injury details(Required)

Mumps details(Required)

Infection details(Required)

Previous treatment details(Required)

Section E – Medical and Surgical History

Operation details(Required)

Please provide details of surgery and when you had the operation

Section F – Vaccination History

Further details(Required)

Section G – Medications History

Medication allergy details(Required)

Section H – Family History

Family history details

Please provide details of any conditions marked ‘Yes’

How many do you smoke per day?

How many units of alcohol do you drink in a week?(Required)

1 standard glass of wine = 1 unit 1 bottle of wine = 10 units 1 pint lager/beer/cider (normal strength) = 2 units 1 shot of a spirit = 1 unit

How many hours of exercise do you do in a week?(Required)

Please complete the following consent details.

Section A – Patient Details

Section B – Partner Details

Section C – Previous Pregnancies

Section E – Medical and Surgical History

Section F – Vaccination History

Section G – Medications History

Section H – Family History

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Section A – Patient Details

Section B – Partner Details

Section C – Previous Pregnancies

Section D – Fertility-related History

Section E – Medical and Surgical History

Section F – Vaccination History

Section G – Medications History

Section H – Family History

Section I – Social History

Section J – Consent