Vasectomy Reversal Pre-Assessment Questionnaire

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

Email

Address Line 1

Mobile Number

Occupation

Address Line 2 (Optional)

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?

No

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? *

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

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

Please specify:

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, or are you currently taking, anabolic steroids or testosterone?

No

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?

No

Yes

Please describe the changes:

Do you smoke?

No

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

Vasectomy Reversal Pre-Assessment
Questionnaire

No Obligation

Confidential

Reviewed by Mr. Jesuraj

About You

Your Vasectomy

Free initial consultation

Consultation fee applies

Your Partner

Your Health

Final Details

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 Reversal Pre-Assessment
Questionnaire