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Occupation:______________________ Referred by: _______________
Reproductive History:
1. Do you have any children? Yes/ No, If yes how many ____Ages_________
2. Duration of unprotected intercourse?________________________________
3. How old is your partner?_________yrs
4. Does your partner have any children? Yes/ No
5. Has your partner had any miscarriages/abortions?
If yes, detail________________________________________________ 6. Has your partner been evaluated for this problem? Yes/ No, If yes, results_______________________________________________
Sexual History:
1. Timing/ frequency of intercourse?___________________________________
2. Problems with erections? If yes detail_______________________________
3. Problems with ejaculations?_______________________________________ 4. Use of lubricants? Yes/ No, If yes name_______________________________
Developmental History:
1. Onset of Puberty___________________________________________
2. Age when you started shaving._____ Do you shave everyday? Yes/ No
3. Any delay in development? Yes/ No, If yes detail__________________ Male infertility questionnaire
Page two
Medical History:

1. Any childhood illnesses? (Circle any that apply) None_____
g. other__________________________________________________ Notes____________________________________________________________________________________________________________________ 2. Any other illnesses? ( Circle all that apply) None______ e. other_________________________________ Notes_____________________________________________________________________________________________________________________ 3. Medications: (Circle all that apply) None_____ Have you ever been on Notes_____________________________________________________________________________________________________________________ Please list all the medications you are on, including over the counter and herbal medications. None_________ Notes _______________________________________________________ ____________________________________________________________ Male infertility questionnaire Page three Surgical History:
h. epididymal surgery i. Testicular biopsy Notes _________________________________________________________ ______________________________________________________________ List all other surgeries and their complications if any: Personal History: (Please circle one)
Do you or have you ever had alcohol? Yes/ No Do you or have you ever used recreational drugs? Notes____________________________________________________ Any additional comments__________________________________________ ______________________________________________________________ ______________________________________________________________ Patient Signature:__________________________________ Dated______________ Name:_______________________________ Age:____________________ Urinalysis:
eukocytes:____Nitrite:____Urobilinogen_____Protein:______Blood:___________Sp.Gravity:________pH:________ K etone:_______Bilirubin:_______Glucose:__________WBC:_______RBC:_______Yeist:______Bacteria:_________ Ep.Cells:_______Crystals:________Casts:_________Other:__________
Physical Examination

1. General ( means normal) BP:__________ Pulse:_______ RR:________ Temp:_________ Height:___________ Weight:_____________ a. Nutrition_____ b. body habitus_______ d. gynecomastia_______ e. secondary sexual characters__________ Urethral opening_______ Plaques_______ Size________ Semen Analysis: Has a semen analysis been done? If yes results.
Notes:__________________________________________________________ _________________________________________________________ _________________________________________________________ Impression: 1.________________________ 2.________________________ 2._____________________________ 3._______________________ Signed ______________________________ Date: ___________________


January 4, 2008

Drugs Offer No Benefit in Curbing Aggression, Study Finds The drugs most widely used to manage aggressive outbursts in intellectually disabled people are no more effective than placebos for most patients and may be less so, researchers report. The finding, being published Friday, sharply challenges standard medical practice in clinics ain the United States and around the world. In recent ye

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Management Issues of Neuropathic Trigeminal Pain from a Medical Perspective The purpose of this article is to review the pharmacological treat- ment of neuropathic trigeminal pain by means of a systematic review. A number of randomized controlled trials and important historical and uncontrolled studies in trigeminal neuralgia and postherpetic neuralgia were identified. Trigeminal neura

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