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Bangholm Medical Centre

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Request an Appointment Online
Practice Forms
Request a Sickline
Send An Image
Become A Patient
Appointments
Prescription Requests
Mental Health Resources
Annual Birthday Reviews
Our Services
Vaccination Information
Health Advice
A-Z of Community Resources

Home
Language
Home
Meet The Team
Our Services
Health Advice
A-Z of Community Resources
Appointment Reminders
Contact Us

Male Fertility Questionnaire

Last Updated: 30/10/2023

Male Fertility Questionnaire

Please feel free to complete this online form only if you are a patient registered with us . It would be good to then book a routine appointment to discuss the results with the GP.

Full Name *

Date of Birth *

Please detail any history of previous successful conception. *

Please give details of smoking status *

heavy smoker (+20 cigarettes a day)

moderate smoker (10-20 cigarettes a day)

light smoker (1-10 cigarettes a day)

non-smoker

ex-smoker

vaper

Other

How much alcohol do you drink per week?

heavy drinking (25 + units per week)

moderate drinking (15 -25 units per week)

light drinking (1-15 units per week)

non-drinker

weight (kg) *

Height (CM) *

Have you had previous genital / prostate surgery or vasectomy in the past? *

Please describe below any past history of testicle or prostate issues. *

Please describe any history of existing known genetic disorder or history of undescended testes.

Any history of being assessed and treated for fertility issues in the past ?

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