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PATIENT CHECK IN WORKSHEET First Name: Middle: Last: Date of Birth: / / SSN: Sex:Home #: () Male/Femaleness #: () Email: Address: Apt/Suite: City: State: Zip Code: Emergency Contact: Phone #: () Relationship:
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Describe any previous treatments or therapies you have undergone for sexual dysfunction or infertility.
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Provide details about any medications or supplements you are currently taking.
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Answer questions regarding your sexual history, including any past or current sexual partners and practices.
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Mention any known medical conditions or diagnoses that may contribute to sexual dysfunction or infertility.
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If applicable, include information about previous pregnancies or attempts at assisted reproductive techniques.
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Sexual dysfunction and infertility forms are typically needed by individuals who are experiencing issues related to their sexual health or reproductive ability. This may include couples having difficulty getting pregnant, individuals with erectile dysfunction, pain during intercourse, or other sexual dysfunctions. Healthcare providers, fertility specialists, or researchers may require these forms to gather relevant information for diagnosis, treatment, or research purposes.
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Sexual dysfunction refers to difficulties experienced during any stage of the sexual response cycle that prevents the individual or couple from experiencing satisfaction from sexual activity. Infertility is the inability to conceive children.
Individuals or couples experiencing sexual dysfunction and infertility may choose to seek medical help and treatment.
To fill out sexual dysfunction and infertility, individuals or couples may need to provide relevant medical history, undergo physical examinations, and possibly fertility tests.
The purpose of addressing sexual dysfunction and infertility is to improve overall sexual health and wellness, as well as to help individuals or couples conceive if desired.
Information such as medical history, symptoms experienced, lifestyle factors, and any previous treatment options may need to be reported for accurate diagnosis and treatment.
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