Vasectomy Encounter Form

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The Medical Procedures Center, P.C.
“We treat people, not just problems.”
John L. Pfenninger, M.D.
4800 N. Saginaw Road
Midland, MI 48640
(989) 631-4545
Visit our Web site at: MPCenter.net
VASECTOMY ENCOUNTER FORM
Date ___________________________________________________
PATIENT TO FILL OUT
Referring Physician _______________________________________
Phone (H)
(W) ________________________________
Name _____________________________________________
Partner’s Name __________________________________________
Age ________ Birthdate _____________________________
Age ________ Birthdate __________________________________
Education _________________________________________
Education ______________________________________________
Occupation ________________________________________
Occupation _____________________________________________
Present for counseling Y
N
st
nd
rd
st
nd
rd
Marriage: 1
2
3
Marriage:
1
2
3
years ____________________________________________
years _________________________________________________
What is the quality of your marriage/relationship? ______________________________________________________________________________
Any marital/relationship problems? _________________________________________________________________________________________
Any sexual problems? ____________________________________________________________________________________________________
Children’s ages and sex ___________________________________________________________________________________________________
Religion
Do you have a religious conflict with vasectomy?
Yes
No
Current contraceptive ____________________________________________________________________________________________________
Are you or your partner experiencing any problems with this? _____________________________________________________________________
Considered tubal ligation? _________________ Other temporary methods? _______________________________________________________
Why do you want a vasectomy? ____________________________________________________________________________________________
How long have you been thinking about limiting your family size? _________________________________________________________________
Your health?
Good
Poor
Partner’s health
Good
Poor
Is there any genetic disease in the family?
Yes
No
If YES, please explain _________________________________________________________________________________________________
Are you concerned about anything in particular in regards to the vasectomy? If so, describe: ____________________________________________
______________________________________________________________________________________________________________________
How well do you tolerate pain?
Well OK
Poorly
Do you have a tendency to faint?
Yes
No
OVER PLEASE

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