(08) 6289 3838
admin@oasisfertilitycentre.com.au
About
Our Team
Services
Fertility Services
Free Fertility Assessment
Donor Program
Donor Program
Egg Donors
Embryo Donors
Sperm Donors
Recipients
Laboratory Services
Service Enquiry
Costs
Success Rate
Resources
Patient Resources
GP Resources
Common Questions
Wellness Centre
Diet & Nutrition
Naturopathy
Acupuncture
Stress & Fertility
Counselling & Psychology
Sound Healing
Make A Booking
MAKE A BOOKING
About
Our Team
Services
Fertility Services
Free Fertility Assessment
Donor Program
Donor Program
Egg Donors
Embryo Donors
Sperm Donors
Recipients
Laboratory Services
Service Enquiry
Costs
Success Rate
Resources
Patient Resources
GP Resources
Common Questions
Wellness Centre
Diet & Nutrition
Naturopathy
Acupuncture
Stress & Fertility
Counselling & Psychology
Sound Healing
Health Questionnaire For Male's
First Name
(Required)
Last Name
(Required)
Have you fathered a child in the past?
(Required)
Yes
No
How many children do you have?
(Required)
How long have you been trying to conceive with your current partner?
(Required)
Do you have any known fertility issues?
(Required)
Yes
No
Please provide details
(Required)
Medical History
Do you experience any difficulties in achieving or maintaining an erection?
(Required)
Yes
No
Have you noticed any recent changes in your libido or sexual desire?
(Required)
Yes
No
Have you previously undergone any testicular surgery?
(Required)
Yes
No
Please provide details
(Required)
Have you been diagnosed with ay chronic medical conditions? (e.g. diabetes)
(Required)
Yes
No
Please provide details
(Required)
Are you currently taking any medications?
(Required)
Yes
No
Please list them
(Required)
Are you currently taking any supplements?
(Required)
Yes
No
Please list them
(Required)
Height (cm)
(Required)
Weight (kg)
(Required)
BMI
(Required)
Lifestyle History
Are you a current smoker/vaper?
(Required)
Yes
No
If yes, how many/day
when did you start
Do you consume alcohol on a regular basis?
(Required)
Yes
No
If yes, how many standard drinks per week?
What is your current occupation?
(Required)
Are you a FIFO worker
(Required)
Yes
No
Family History
Do you have a family history of fertility issues?
(Required)
Yes
No
Please provide details
(Required)
Do you have a family history of genetic disorders or birth defects?
(Required)
Yes
No
Please provide details
(Required)
Do you have a family history of chronic medical conditions?
(Required)
Yes
No
Please provide details
(Required)
Additional Information
Please feel free to provide any other relevant information
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