PATIENT DETAILS

ABOUT YOU

Name

Address

Date of Birth

Height

Weight

Name and address of your GP

Occupation

Email

Home Telephone number

Mobile Telephone number

Preferred contact method

ABOUT YOUR VASECTOMY

How long ago was your vasectomy

Have you already had an attempt at vasectomy reversal

ABOUT YOUR HEALTH

Do you have any medical problems

Do you have any chest, breathing or heart problems?

Have you had any form of surgery?

Are you on any medications and what are they?

Do you have any allergies

Have you or a close relation had any problems with a general anaesthetic?

ABOUT YOUR PARTNER

How old is your partner?

Has she had children previously?

Does your partner have any known potential fertility problems?