Genitrix

Man Form

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First name

Address

Last name

City

Date of birth

Zip code

Phone number

Country

Height

E-mail

Weight

Occupation

Partner's name

1) Do you regularly take any medication? If so, state their name and dosage.

2) Have you been treated for any serious illness in the past?

3) Have you ever had an operation? If so, when and what type of operation was it?

4) Do you have children? If so, when were they born? With the same partner?

When was the last time you had a semen analysis?

I have never had a semen analysis

When was the last time you were tested for sexually transmitted diseases (STDs)?

HIV, Hepatitis B, Hepatitis C, Syphilis - positive result (what diseases):

All negative

I have never been tested for sexually transmitted diseases (STDs)

Have you had a genetic analysis, karyotype?

I have never had genetic testing.

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Please note that all information is confidential and must reflect your current state of health, so please make sure to fill out the form correctly.