Questionnaire for the man

Contact information

First name*
Surname*
CPR number or date of birth (dd-mm-yy)*
Address*
Postal code*
City
Country*
Phone number*
E-mail*

General questions

Occupation

What is your job occupation?*

Medical history

Are you allergic to any type of medicine?*
Please specify the type of medicine and the type of allergic reaction*
Do you take any medicine on a daily basis?*
Which medicine and what dosage? (nutritional supplements excluded)*
Do you have any medical or mental illnesses?*
Please describe the illnesses by diagnoses or short descriptions*
Have you ever had surgery? (orthopedic surgery excluded)*
Please describe your previous surgeries*
Are there other matters which are important for us to know about your medical and mental health?*
Please describe here*

Lifestyle

How tall are you? (please specify height in cm)*
What do you weigh? (Please specify weight in kg)*
How many units of alcohol do you consume in a week? (average consumption)*
Do you smoke?*
How many cigarettes do you smoke daily? (average consumption)*
Do you use other tobacco preparations? (snus/snuff, vape, e-cigarette, other)*
Please describe the sort of tobacco and the amount used daily*
Have you ever taken anabolic steroids?*
Please describe the time period where you used anabolic steroids*
Have you ever used finasterid? (medication for hair loss)*
Please describe the time period where you used finasterid*
Do you exercise?*
Please describe your choice of exercise and time spent weekly*
Do you take any supplements?*
Please specify the supplements here*
Are there other things which are important for us to know about your lifestyle?*
Please describe here*

Sperm quality and diseases in the testicular organs

Have you had a sperm analysis done?*
Please describe the result of the sperm analysis*
Have you had problems with the testicles not being in the scrotum when you were a child?*
Did you have medication or surgery to treat it?*
Have you had surgery for an inguinal hernia?*
Have you had problems with your testicles, epididymis or penis that could affect your fertility? e.g. infections, operations or the like*
Please describe here*

Have you ever made a woman pregnant?

Have you ever made a woman pregnant?*
Do you have children?*

Previous fertility treatment

Have you previously undergone fertility treatment?*
Please specify the sort of prior fertility treatment here*

Final questions

Are there other matters which are important for us to know?*
Please describe here*
How did you hear about and choose Trianglen as your fertility clinic?*
Please describe here*