What is your Age:

What is your weight in kg:

What is your height in cm:

Do You Smoke:

Yes
No

Do you consume more than 2 serves of alcohol per day?:

Yes
No

Do you consume more than 2 cups of coffee per day?:

Yes
No

Have you ever been diagnosed with Chlamydia?:

Yes
No

Have you ever been diagnosed with congenital absence of the vas?

Yes
No

Have you ever taken anabolic steroids?

Yes
No

Have you ever taken recreational drugs?

Yes
No

Have you been attempting to get your partner pregnant for greater than 6 months?

Yes
No

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