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Vasectomy
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Testing form
Peak Medical
2023-08-13T04:57:06-04:00
Demographics
First Name
*
Preferred name (how you prefer to be addressed)
*
Last Name
*
Mailing Address
Postal Code
Date of Birth
*
Family Physician
*
Alberta Health Care Number
*
Occupation
Phone Number
*
Email Address
*
Level of exertion at work:
Light: No climbing or lifting (e.g. office work)
Moderate: Some climbing or lifting (up to 30 pounds)
Heavy: Heavy lifting
MEDICAL AND SURGICAL HISTORY
Please list any prescribed medication including Testosterone
Please list any medication allergies:
Do you specifically take any blood thinners (including aspirin)?:
*
Yes
No
Do you consent to having your visit record from today’s visit sent to your Family Physician?
Yes
No
Have you had any of the following operations? (check Yes or No):
Hernia surgery as an adult
*
Yes
No
Hernia surgery as an infant or child
*
Yes
No
Any other type of scrotal or testicular surgery
*
Yes
No
Surgery for a torsion/twisted testicle
*
Yes
No
Removal of a testicle
*
Yes
No
Surgery as a child for undescended testes
*
Yes
No
Prior vasectomy or prior vasectomy and reversal
*
Yes
No
Please list any other operations you may have had:
Have you ever had any of the following problems? (check Yes or No):
Problems with bleeding or easy bruising
*
Yes
No
Difficulty getting or maintaining erections
*
Yes
No
Premature ejaculation
*
Yes
No
Difficulty reaching climax
*
Yes
No
Herpes
*
Yes
No
Genital warts
*
Yes
No
HIV
*
Yes
No
Epididymitis (infection around the testicle)
*
Yes
No
Varicocele (dilated blood vessels in the scrotum)
*
Yes
No
Hydrocele (fluid collection in the scrotum)
*
Yes
No
Tendency to get lightheaded or faint when having or witnessing medical procedures or tests
*
Yes
No
FAMILY INFORMATION
Your Age
Marital status:
*
Married
Single
Separated
Steady Partner
Casual Partner
Partner's Full Name
Partner's Age
*
Your partner’s permission is not required for your vasectomy, but are they aware you are having one? (check):
*
Yes
No
How would you refer to yourself with regards to your partner?
*
Husband
Fiance
Boyfriend
Partner
N/A
Number of years with present partner:
*
Number of children you have with present partner:
1
2
3
4
5
6
7
8
9
10 or more
Total number of children you have had:
1
2
3
4
5
6
7
8
9
10 or more
Total number of children your current partner has had:
0
1
2
3
4
5
6
7
8
9
10 or more
Age of your youngest child (in years):
Less than 1
1
2
3
4
5
6
7
8
9
>10
Were your children all planned?
*
Yes
No
N/A
Is your partner pregnant now?
*
Yes
No
N/A
Has your partner had their tubes tied or undergone hysterectomy?
*
Yes
No
N/A
PRIMARY method of birth control in the last few months:
No birth control
Oral birth control pills
Condoms
Diaphragm (female condom)
IUD (Mirena, Kyleena, Liberte copper)
Implant (Nexplanon)
Injection (Depo-Provera)
Before submitting the form, please review and agree to the following by checking the box:
You have read the information provided on our website regarding no-needle, no-scalpel vasectomy.
If you have a history of fainting, it's advised to bring a driver with you for the procedure.
Refrain from alcohol consumption 24 hours before and after the procedure.
Avoid taking aspirin or anti-inflammatory drugs (NSAIDs) such as Ibuprofen, Advil, Motrin, Aleve, etc., for 7 days before and after the operation unless advised otherwise.
If you are taking Warfarin, Apixaban (Eliquis), Rivaroxaban (Xarelto), Dabigatran (Pradaxa) or Edoxaban (Lixiana), please ensure you have listed it in the appropriate box above and Dr. Randeva will call you directly to discuss what to do. Do not just stop it.
Have a discussion with your partner about the decision to undergo a vasectomy, and ensure they are supportive of your choice. Feel free to contact our office to discuss further if needed.
You will have ample opportunity to ask any questions or discuss concerns with Dr. Randeva prior to your procedure.
Be aware that failure to follow
Before Vasectomy Instructions
or cancellation with short notice may incur a $200 cancellation fee.
Patient Signature
*
Date
*
Submit
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