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 Please SelectEmailHome Telephone numberMobile Telephone number 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?