Reproductive History Have you had a vasectomy failure or vasectomy reversal? Yes No

Have you had a semen analysis with abnormal result ( e.g. shape/ low count)? Yes No

Did you notice change in amount of ejaculate or pain or loss of erection during sexual activity? Yes No

Do you have injury on your testicles? Yes No

Do you have a spinal cord injury, cancer or prostatic? Yes No

Have you had surgery or any trauma in scrotum area in the past? Yes No

Have you ever diagnosed with a sexual transmitted diseases ? Yes No

Your Life Style Have you been exposed to environmental risk (e.g. hot tub, lead, pesticide)? Yes No

Do you  smoke heavily? Yes No

Do you have diabetics? Yes No

Do you have  thyroid disease or heart disease? Yes No

Are you obese? Yes No

Do you have undescended testicles, variable or other sex organ issues? Yes No

Do you drink heavily, takes marijuana or cocaine? Yes No

Have you had developmental problems such as birth defects? Yes No