Male Fertility Assessment Survey
Please complete this survey to help assess factors related to male fertility. Your responses are confidential and will contribute to a better understanding of your reproductive health.
Full Name
*
First Name
Last Name
Age
*
Have you experienced any difficulties in conceiving a child?
*
Yes
No
Do you currently smoke or use tobacco products?
*
Yes, regularly
Occasionally
No
How often do you consume alcoholic beverages?
*
Please Select
Never
Rarely (less than once a week)
Occasionally (1-3 times per week)
Frequently (4 or more times per week)
Do you have any known chronic health conditions (e.g., diabetes, hypertension, varicocele)?
*
Diabetes
Hypertension
Varicocele
None
Other
Submit Assessment
Should be Empty: