Vasectomy Reversal Pre-Assessment
Questionnaire

Mr. Manohar Jesuraj, Consultant Urological Surgeon, reviews every questionnaire personally. Our team will then contact you by email or phone within two working days to offer a consultation date. All first-time reversal patients qualify for a free initial remote video consultation.

No Obligation

Confidential

Reviewed by Mr. Jesuraj

Vasectomy Reversal Pre-Assessment Questionnaire

About You
Your Vasectomy
Your Partner
Your Health
Final Details

About You

Let’s start with your contact details so we can get in touch by email or phone to arrange your consultation.

First Name

Last Name

Date of Birth

Address Line 1

Mobile Number

Occupation

Address Line 2

City

Post Code (Optional)

County

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

Your Vasectomy

These details help Mr. Jesuraj assess the best surgical approach.

Approximately when did you have your vasectomy?

Did you have any complications after your vasectomy?

Yes

If Yes, Describe any complications

Have you had a previous vasectomy reversal attempt?

No — this is my first reversal

Yes — I have had a previous reversal

What is your reason for seeking a reversal?

✓

Free initial consultation

All first-time reversals (options 1–3) qualify for a complimentary remote video consultation.

Consultation fee applies

Redo reversals and pain enquiries (options 4–5) require a chargeable remote video consultation.

Fertility restoration — new relationship

Fertility restoration — existing relationship

Personal reasons — not for fertility restoration

Redo reversal — fertility restoration

Pain or discomfort (post-vasectomy pain syndrome)

How many biological children do you have?

Age of youngest?

Your Partner

Your partner’s details help Mr. Jesuraj give you the most accurate assessment of your combined chances of success.

Partner’s First Name (optional)

Partner’s Age

Does your partner have any children? *

Yes

How many?

Age of youngest?

Does your partner have any known gynaecological problems?

Yes — please give details

Not known

Have you or your partner previously considered or undergone IVF?

Yes

Considered but not proceeded

Please select your reason for seeking a reversal in Section B — this determines whether we need your partner's details.

Your Health

Do you have any significant medical conditions?

Diabetes

Heart Disease

Fits/Faints

High Blood Pressure

Asthma

None

Other condition — please specify below

Please specify:

Have you had any previous surgery to the scrotum or groin?

Yes — details

Are you currently taking any prescribed medicines?

Do you have any known allergies to medicines?

Have you ever taken, or are you currently taking, anabolic steroids or testosterone?

Yes

How long have you been taking anabolic steroids or testosterone?

When was the last time you took anabolic steroids or testosterone?

What type(s) of anabolic steroids or testosterone have you used?

Have you noticed any changes in your testicles since using these substances?

Yes

Please describe the changes:

Do you smoke?

Yes

Ex-smoker

How many cigarettes do you smoke per day?

How long have you been smoking?

When did you stop smoking?

How many cigarettes per day did you smoke previously?

For how many years did you smoke?

Alcohol (units/week)

Height

Weight

Are you able to lie still and flat on your back for approximately 3 hours?

No — I have back problems

Yes

Final Details

How did you find our service?

Online search engine

Recommendation

Other

Have you researched your options, including microsurgical reversal and IVF?

No — I am just starting to look into it

Yes — I have done significant research

Some research

How soon are you hoping to have the procedure?

As soon as possible

Within 3 months

Within 6 months

Just researching for now

Is there anything else you would like Mr. Jesuraj to know? (Optional)

I consent to being contacted regarding my enquiry

First Name

Last Name

Free Consultation Enquiry

Vasectomy Reversal
Questionnaire

✓ No Obligation ✓ Confidential ✓ Reviewed by Mr. Jesuraj

About You

Your Vasectomy

Your Partner

Your Health

Final Details

About You

Let’s start with your contact details so we can get in touch by email or phone to arrange your consultation.

First Name *

Last Name *

Date of Birth *

Mobile Number *

Email Address *

We will contact you by email or phone to arrange your consultation.

Home Address *

Your Vasectomy

These details help Mr. Jesuraj assess the best surgical approach.

Approximately when did you have your vasectomy? *

Did you have any complications after your vasectomy? *

No Yes — please give details

Have you had a previous vasectomy reversal attempt? *

No — this is my first reversal Yes — I have had a previous reversal

Please provide as much detail as you can.

When was the previous reversal?

Where was it performed?

What was the outcome?

What is your reason for seeking a reversal? *

✓ Free initial consultation

All first-time reversals (options 1–3) qualify for a complimentary remote video consultation.

£ Consultation fee applies

Redo reversals and pain enquiries (options 4–5) require a chargeable remote video consultation.

1Fertility restoration — new relationshipFree 2Fertility restoration — existing relationshipFree 3Personal reasons — not for fertility restorationFree 4Redo reversal — fertility restorationFee applies 5Pain or discomfort (post-vasectomy pain syndrome)Fee applies

How many biological children do you have? *

Age of youngest? *

Your Partner

Your partner’s details help Mr. Jesuraj give you the most accurate assessment of your combined chances of success.

Why we ask about your partner: Success rates depend on both partners’ circumstances.

Partner’s First Name (optional)

Partner’s Age *

Does your partner have any children? *

No Yes

How many?

Age of youngest?

Does your partner have any known gynaecological problems? *

No Yes — please give details Not known

Have you or your partner previously considered or undergone IVF? *

No Considered but not proceeded Yes — please give details

Partner details not required
As your enquiry relates to post-vasectomy pain, we do not need your partner’s details. Please continue to the next section.

Please select your reason for seeking a reversal in Section B — this determines whether we need your partner’s details.

Your Health

These questions help us plan your anaesthetic and procedure safely.

Do you have any significant medical conditions? *

Diabetes High Blood Pressure Heart Disease Asthma Fits/Faints None Other condition — please specify below

Have you had any previous surgery to the scrotum or groin? *

No Yes — details

Are you currently taking any prescribed medicines? *

Do you have any known allergies to medicines? *

Have you ever taken testosterone or anabolic steroids? *

No Yes

Do you smoke? *

No Ex-smoker Yes

Alcohol (units/week) *

Height *

Weight *

Occupation *

Are you able to lie still and flat on your back for approximately 3 hours? *

Yes No — I have back problems

Final Details

Almost done — just a few last questions.

How did you find our service? *

Online search engine Recommendation Other

Have you researched your options, including microsurgical reversal and IVF? *

Yes — I have done significant research Some research No — I am just starting to look into it

How soon are you hoping to have the procedure? *

As soon as possible Within 3 months Within 6 months Just researching for now

Is there anything else you would like Mr. Jesuraj to know? (optional)

I consent to being contacted regarding my enquiry. *

Vasectomy Reversal Pre-AssessmentQuestionnaire

No Obligation

Confidential

Reviewed by Mr. Jesuraj

About You

Your Vasectomy

Free initial consultation

Consultation fee applies

Your Partner

Your Health

Final Details

Vasectomy ReversalQuestionnaire

About You

Your Vasectomy

Your Partner

Your Health

Final Details

Vasectomy Reversal Pre-Assessment
Questionnaire

Vasectomy Reversal
Questionnaire