Male Fertility Screen Questionnaire
These questions have been designed to give a clear picture of your present health status
and to identify any potential health problems that may affect your fertility. All your
answers are confidential and will only be seen by the health assessor.
Once completed, save the form as:
Male_Fertility_xxxxxxxxxxx.docx (insert your first and last name) and upload at
www.pulsescreening.co.uk/tel_consult.html.
Date:
Name: Tel No:
Address: Email:
Age: Date of Birth:
Occupation: Ethnic Origin:
Personal Medical History:
Please put a Y for Yes and leave blank for No. If you are unsure, put ? in box.
If you answer YES, please give brief details in Supplementary Information section
1) Do you, or have you ever suffered from any of the following cardiovascular
disorders?
High Blood Pressure High Cholesterol Irregular Pulse Palpitations
2) Do you, or have you ever suffered from any of the following nervous disorders?
Anxiety Depression Stress Anorexia/Bulimia
3) Do you, or have you ever suffered from any of the following urinary system
disorders?
Kidney
Recurrent Cystitis Stress Incontinence (leaking urine)
Disease
4) Do you, or have you ever suffered from any of the following endocrine disorders?
Diabetes
Diabetes Type 2 Thyroid Disease Other Glandular Disease
Type 1
5) Have you ever been diagnosed with any form of the following?
Cancer Tumour Cyst Lump
If yes, where in the body?
Pulse Health Screening, Tel: 01234 840089, enquiries@pulsescreening.co.uk, www.pulsescreening.co.uk
6) Do you, or have you ever suffered from any of the following blood disorders?
Iron-Deficiency Pernicious
Leukaemia Sickle Cell Disease/Thalassaemia
Anaemia Anaemia
7) Have you ever undergone any of the following investigations?
If yes, give details in Supplementary Information
MRI Blood
Xray ECG CT Scan Ultrasound Other
Scan Tests
8) Have you ever undergone a genitor-urinary surgical operation? If yes, give details in
Supplementary Information
Supplementary Information
Please insert question number and relevant details in the space provided
Question
Brief Details ie. condition, dates, investigations, duration of treatment etc
Number
Genito-Urinary History:
Do you routinely examine your testicles for lumps?
Have you ever noticed a lump? If yes, did you seek medical advice?
What was the outcome?
Have you ever been diagnosed with a sexually transmitted disease?
If yes, please state the name of the disease(s)
How long ago did you have the disease?
What treatment were you given?
Pulse Health Screening, Tel: 01234 840089, enquiries@pulsescreening.co.uk, www.pulsescreening.co.uk
Do you ever suffer with erectile dysfunction (impotence)?
If yes, have you received treatment for this?
What was the treatment?
Have you ever been treated for Infertility?
Have you had a Sperm Count test? If yes, what was the number?
Have you had a blood test for toxic heavy metals?
Have you ever had a Hair Mineral Analysis for toxic metals and mineral ratios?
Have you had a hormone profile test? Blood Test Saliva Test
Do you currently take any medication? If yes, please state the name of the drug(s) you
take, dosage and how often.
Name of Drug Dosage Times a Day
Do you currently take any dietary supplements? If yes, please state the name of the
supplements you take, dosage and how often.
Name of Supplement Dosage Times a Day
Exercise:
Do you do any form of exercise/activity?
If yes, what do you do?
How often do you do this?
Do you have a sedentary job/lifestyle?
Pulse Health Screening, Tel: 01234 840089, enquiries@pulsescreening.co.uk, www.pulsescreening.co.uk
Smoking Status:
Do you If yes, put X in box of what
Cigarettes Cigars Pipe Other
smoke? you smoke
How many a day?
If you do not smoke, have you ever smoked? When did you stop?
If yes, put X in box of what you smoked Cigarettes Cigars Pipe Other
When did you stop smoking?
Alcohol Status:
(one unit = ½ pt beer, small glass of wine, pub measure of spirits)
What is your average weekly consumption of alcohol in units?
If less than 1 unit, how many in a month?
Did you regularly drink more in the past? If so, how many units a week?
Allergies or Intolerances:
Do you suffer from any allergies?
If yes, what are you allergic to?
Has your allergy been confirmed by a specialist or test?
Do you suffer from any food intolerances?
If yes, what are you intolerant to?
Has your intolerance been confirmed by a specialist or test?
Dietary History:
Do you eat at least 3 meals a day?
If not, which meal(s) do you miss?
Do you eat at least 5 portions of fruit and vegetables a day?
Do you eat meat? Do you eat fish? Are you a Vegetarian? Are you a Vegan?
Do you include roughage (high fibre foods) in your diet?
Do you eat convenience/processed food and takeaways? If yes, how often?
Pulse Health Screening, Tel: 01234 840089, enquiries@pulsescreening.co.uk, www.pulsescreening.co.uk
<1 a week 1-2 x a week 3-6 x a week Every day
Do you eat organic produce? Regularly Occasionally Rarely
Do you usually add sugar to beverages or breakfast cereals?
Do you use artificial sweeteners? If so, which brand?
Do you consume dairy products? Do you eat margarine? If so, which brand?
How many glasses of water do you drink a day? Do you drink tap water?
Is your water fluoridated? Do you use a water filter? If yes, what type?
Do you drink caffeinated tea or coffee? No. of cups of tea No. of cups of coffee
Do you drink fizzy drinks? How many a week? Do you drink diet versions?
Do you use a Microwave oven to cook, defrost or reheat food/drink?
Do you regularly eat your main meal after 7pm?
Environmental:
Do your toiletries contain any of the following ingredients?
Sodium Lauryl Sulphate Sodium Laureth Sulphate Propylene Glycol DEA / TEA / MEA
Talc DMDM hydantoin Imidazolidinyl urea Butylated hydroxytoluene
Aluminium Triclosan Isopropyl Petrolatum/Mineral Oil
Do you use air fresheners (any type)?
Do you use supermarket or main brands of household cleaning products?
Do you usually get 8 hours of sleep a night? Less More
What time do you normally go to bed? What time do you normally get up?
Does your work include night shifts
Do you take more than half an hour to get to sleep?
Do you wake during the night?
Do you make time to relax each day?
Do you use a mobile phone? Regularly (several times a day) Occasionally (less than 3 times a week)
What percentage of your mobile phone use is for making calls? (excluding texting and other activities) %
Where do you keep your mobile phone when it is switched on? (e.g. pocket, bag etc.)
Do you use a cordless (DECT) phone at home or work?
If yes, where is the base station situated?
Do you have a WiFi Router at home or work? Work Home
Pulse Health Screening, Tel: 01234 840089, enquiries@pulsescreening.co.uk, www.pulsescreening.co.uk
If you have WiFi at home, do you turn it off at night?
Do you live or work within 100 metres of any of the following?
Mobile Phone Mast Electric Pylon Electric Sub-Station
Do you have a television in your bedroom?
If yes, do you turn it off from the mains before going to sleep?
Do you keep any of the following switched on beside or near your bed at night?
Mobile phone Cordless (DECT) phone Electric Radio/Alarm Baby Monitor
Are you currently suffering from any emotional stress? e.g family problems, financial worries etc.
Do you live with a pet? If yes, what type of pet(s) do you have?
Do you clean up your pet’s excrement?
Family History:
Have close family members suffered from any of the following?
Please put M for Mother, F for Father, S for Sister or B for Brother
Stroke Heart Attack High Blood Pressure High Cholesterol
Diabetes Type 1 Diabetes Type 2 Cancer Type of cancer
Measurements of Health:
Instructions are available at www.pulsescreening.co.uk/tel_consult.html
Height: Weight: Body Mass Index:
Blood Pressure: Pulse Pressure: Pulse:
Waist: Hips: Waist to Hip Ratio:
Pulse Health Screening, Tel: 01234 840089, enquiries@pulsescreening.co.uk, www.pulsescreening.co.uk