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Male Assessment
1.
Please indicate your partners age group.
Select one
<20
20-25
26-30
31-35
36-40
>40
2.
How long have you been actively trying to achieve a pregnancy?
select one
<3 months
3-6 months
7-12 months
13-24 months
>24 months
3.
How many times, on average, do you and your partner have intercourse in a month?
select one
<1
1-4
5-10
11-20
21-30
>30
4.
Does your partner experience pain after or during intercourse?
Yes
No
Unknown
5.
Does your partner have a blockage in the fallopian (uterine) tubes?
Yes
No
Unknown
6.
Has your partner had previous infections in the fallopian tubes?
Yes
No
Unknown
7.
Does your partner have any abnormalities of the uterus?
Yes
No
Unknown
8.
Does your partner suffer from endometriosis?
Yes
No
Unknown
9.
Does your partner have irregular periods?
Yes
No
Unknown
10.
Do you have a low sperm count?
Yes
No
Unknown
This page was last updated on
This page was last updated on October 11, 2001
