Vasectomy Pre-Assessment
Questionnaire

This confidential questionnaire guides you through everything you need to know, screens for clinical suitability, and prepares you for direct booking or a short consultation. It takes approximately 8–10 minutes.

8–10 minutes

Confidential & Secure

Clinically reviewed

Consultant Urological Surgeon

Vasectomy Pre-Assessment Questionnaire

Personal Details
Fertility & Decision
Counselling & Education
Decision Commitment
Booking Preference
Medical History
Scrotal History
Lifestyle
Declaration

Personal Details

Your contact information helps us prepare your records and reach you to confirm your appointment.

First Name

Last Name

Date of Birth

Address Line 1

Mobile Number

Occupation

Address Line 2 (Optional)

GP Name & Practice (optional)

I consent to being contacted by phone, WhatsApp, or email regarding my care at Tees Urology / Best Life Clinic.

Fertility Status & Decision Context

Understanding your current family situation helps us support your decision appropriately.

Do you have children?

Yes

How many children?

Are you currently in a stable relationship?

Yes

Have you discussed vasectomy with your partner?

Yes

Prefer not to say

Not Applicable

Are you certain you do not want more children in the future?

I am still unsure

Mostly certain, but have some doubt

Yes, I am certain

Have you considered and ruled out other long-term contraceptive options? For example: female sterilisation, long-acting reversible contraception (LARC).

Not yet

Partially - I'd like to discuss further

Yes, I have considered alternatives

Counselling & Education

Please read each section carefully. Tap any heading to expand the full information. You will confirm your understanding on the next step.

~6%

of men later regret vasectomy

5–15%

experience some long-term discomfort

<1 in 2,000

chance of late failure

15–20 min

typical procedure time

Vasectomy is Permanent Contraception

Vasectomy involves dividing and sealing the vas deferens — the tubes that carry sperm — so that sperm can no longer be released during ejaculation. Hormone production and sexual function are not affected.

You should approach this decision as if it cannot be undone. The procedure is classified as a permanent method of contraception, and planning for reversal as a fallback is strongly discouraged.

Can It Be Reversed?

Reversal is technically possible, but comes with important caveats:

Requires specialist microsurgery — significantly more complex than vasectomy itself
Not routinely available on the NHS — usually self-funded privately
Expensive — typically £3,500–£5,000 or more
Success rates decline with time since vasectomy
Technical success does not guarantee pregnancy

Mr. Jesuraj offers microsurgical vasectomy reversal using the Microdot technique with success rates up to 90%+ when performed within the optimal timeframe — but this should not influence the decision to proceed with vasectomy.

Contraception Must Continue After the Procedure

Vasectomy does not take effect immediately. Sperm stored in the reproductive tract can remain for several months.

You must continue using contraception until a semen test — usually around 12 weeks after the procedure — confirms no sperm are present. We will arrange this test for you.

About the Procedure Itself

Day-case procedure, typically 15–20 minutes
Performed under local anaesthesia — you are awake but the area is fully numb
Usually via no-scalpel technique — a small puncture, not an incision
Occasionally a small incision is needed if anatomy is difficult
Return to desk work typically within 2–3 days; physical work within 5–7 days
Sexual activity usually resumed after approximately one week

Risks & Complications

~6%

RISK OF REGRET

Around 6 in 100 men later regret vasectomy — most commonly following a relationship change or unexpected bereavement.

5–15%

CHRONIC SCROTAL DISCOMFORT

Long-term testicular or scrotal discomfort is reported in 5–15% of men. Around 5% may need further treatment.

<1 in 2,000

LATE FAILURE

Very rarely the vas deferens rejoins spontaneously. The semen test at 12 weeks detects this.

1–2%

HAEMATOMA

A blood collection in the scrotum occurs in around 1–2% of cases, usually resolving without intervention.

If you feel unsure at any stage, you are encouraged to pause and seek further discussion before proceeding. There is no pressure to continue today.

Decision Commitment

Please confirm each statement below. All six must be ticked before you can continue. This forms part of your informed consent record.

I understand that vasectomy is intended to be permanent and I am not relying on reversal as a fallback.

I understand reversal is complex, expensive, not routinely available on the NHS, and success is not guaranteed.

I understand I must continue using contraception until a semen test at 12 weeks confirms success.

I understand the risks of regret (~6%) and chronic scrotal discomfort (5–15%), and that further treatment may occasionally be needed.

I have considered alternative contraceptive options and wish to proceed with vasectomy.

I confirm I have considered this decision carefully and am making it freely, without pressure from any other person.

Booking Preference

Having confirmed the above, how would you like to proceed? A consultation is always available if you have remaining questions.

What Happens After You Submit?

Review — Your questionnaire is reviewed by Mr. Jesuraj or our clinical team within one working day

Confirmation — You receive a direct booking link or recommendation for a short consultation

Procedure — Typically arranged within a few days at Best Life Clinic, Stockton-on-Tees

Semen test at 12 weeks — Arranged by us to confirm the procedure has been successful

How would you like to proceed?

Proceed to Direct Booking - I am ready to proceed and would like to book my vasectomy directly

Short Consultation First - I would like a brief conversation with Mr. Jesuraj before making a final decision

Preferred days or times

Monday: Morning & Early Afternoon slots

Tuesday: Afternoon slots

Thursday: Afternoon slots

How did you hear about us? (optional)

Medical History

This information ensures the procedure is safe for you and allows appropriate planning.

Do you have any ongoing medical conditions?

Do you take any regular medications?

Are you taking any blood-thinning medications? Includes: warfarin, rivaroxaban, apixaban, clopidogrel, prescribed aspirin, or similar.

Not Sure

Yes

Please specify the medication(s) and dose:

Do you have any known drug allergies?

Yes

Please describe the allergy and reaction:

Have you had any previous surgery under general or local anaesthetic?

Yes

Please describe the procedure(s) and any complications:

Urological & Scrotal History

Previous scrotal conditions or surgery can affect the approach to vasectomy. Please answer honestly — all information is confidential.

Have you had any previous surgery on your scrotum, groin, or testicles?

Yes

ⓘ

Clinician review recommended

Previous scrotal or groin surgery may make the vas deferens harder to access. Mr. Jesuraj will review your history before confirming your booking.

Please describe the surgery and approximate date:

Have you experienced any of the following? Tick all that apply:

Chronic or recurrent testicular / scrotal pain

Epididymitis or orchitis (infection or inflammation of the testicle or epididymis)

Significant scrotal or testicular trauma

Swelling, hydrocele, or varicocele

Testicular lump or mass (ever investigated or treated)

None of the above

Clinician review recommended

If you have clinical concerns or a history of scrotal surgery, Mr. Jesuraj will review your details before your procedure date is finalized.

Any other known scrotal or urological conditions?

Lifestyle & General Health

A few final background questions to complete your pre-assessment profile.

Height (optional)

Weight (optional)

Smoking status

Never Smoked

Former Smoker

Current Smoker

Do you have a responsible adult who can collect you and stay with you for 24 hours?

Not sure yet

No / Need to arrange

Yes

Health insurance (optional)

Is there anything else you would like us to know? (optional)

Final Declaration & Consent

Please read and confirm the declaration below. This forms part of your pre-assessment record.

Declaration

By submitting this questionnaire, I confirm that:

The information I have provided is accurate and complete to the best of my knowledge
I have read and understood the information about vasectomy, including its permanence, risks, and post-procedure requirements
I understand this questionnaire does not constitute binding consent to surgery — formal written consent will be taken on the day of the procedure
I am making this decision freely and without pressure from any other person
I understand I may withdraw at any time before the procedure without any effect on my care

I confirm the information provided is accurate and complete.

I confirm I understand the risks, benefits, and limitations of vasectomy as described.

I confirm this decision is made freely and without pressure.

I consent to this information being stored securely and used to support my care at Best Life Clinic / Tees Urology.

Your data is held securely and confidentially by Best Life Healthcare Ltd (CQC registered, Co. no. 06711746) in accordance with UK GDPR and the Data Protection Act 2018. It will not be shared without your consent except where required by law.

Vasectomy Pre-AssessmentQuestionnaire