BOOKING AN APPOINTMENT

Level of exertion at work

Marital Status

If you have a partner, is she aware that you are taking an appointment for a vasectomy?

My partner is pregnant.

What method of birth control are you using now?

Does your child have any family history of bleeding disorders (e.g., hemophilia)?

Have you ever been diagnosed with any medical conditions?

Do you take prescription medications?

Do you take non-prescription drugs (aspirin)?

Are you allergic to any medications?

Do you have any bleeding problems?

Have you ever fainted or do you get queasy/faint with medical things like a blood test?

Have you ever had surgery to the scrotum or testicles including, but not limited to vasectomy, undescended testicles, torsion of the testicles, hydrocoele, varicocoele, hernia repair in childhood, tumor/cyst,growth in the scrotum or removal of a testicle?

Have you ever had genital herpes or genital warts?

Have you ever had a disease that can be transmitted by blood including, but not limited to, hepatitis or AIDS?

Have you ever had pain in the scrotum due to epididymitis or other cause?

Have you ever been diagnosed with any medical conditions?

Do you take prescription medications?

Do you take non-prescription drugs (aspirin)?

Are you allergic to any medications?

Do you have any bleeding problems?

Have you ever fainted or do you get queasy/faint with medical things like a blood test?

Have you ever had surgery to the scrotum or testicles including, but not limited to vasectomy, undescended testicles, torsion of the testicles, hydrocoele, varicocoele, hernia repair in childhood, tumor/cyst,growth in the scrotum or removal of a testicle?

Have you ever had genital herpes or genital warts?

Have you ever had a disease that can be transmitted by blood including, but not limited to, hepatitis or AIDS?

Have you ever had pain in the scrotum due to epididymitis or other cause?

Has your child ever been diagnosed with any medical conditions such as bleeding disorders, hypospadias, or methemoglobinemia?

Does your child take any prescription medications (sulfonamides)?

Does your child take any non-prescription drugs (aspirin)?

Is your child allergic to any medications (e.g., lidocaine, prilocaine)?

Has your child ever undergone a surgery on the genital area?

Has your child ever been diagnosed with a blood transmitted disease including, but not limited to, AIDS?