[ { "page": 1, "items": [ { "page": 1, "type": "TITLE", "location": { "l": 181.68, "t": 754.08, "r": 428.88, "b": 736.8 }, "text": "Instructions for Semen Analysis", "reading_order": 0, "level": 1 }, { "page": 1, "type": "TEXT", "location": { "l": 69.84, "t": 719.52, "r": 529.44, "b": 706.32 }, "text": "Please begin to follow these instructions at least 4 days before producing your semen sample.", "reading_order": 1 }, { "page": 1, "type": "LIST_ITEM", "location": { "l": 68.88, "t": 697.44, "r": 540.96, "b": 663.36 }, "text": "Abstain from ejaculation for 2 days prior to your appointment. Frequent ejaculation is encouraged leading up to the appointment, but a maximum 2 days of abstinence is required for an accurate analysis.", "marker": "•", "list_id": "L1", "level": 0, "reading_order": 2 }, { "page": 1, "type": "LIST_ITEM", "location": { "l": 69.6, "t": 661.92, "r": 540.72, "b": 639.36 }, "text": "For post-vasectomy analysis, it is required that the test be done at least 12 weeks post-surgery, and that you ejaculate a minimum 20 times prior to help clear any remaining sperm from the vas deferens.", "marker": "•", "list_id": "L1", "level": 0, "reading_order": 3 }, { "page": 1, "type": "LIST_ITEM", "location": { "l": 68.88, "t": 637.68, "r": 540.48, "b": 615.36 }, "text": "Please write your name and date of birth on the sample container, and wash and dry your hands and genitals thoroughly before collecting the sample.", "marker": "•", "list_id": "L1", "level": 0, "reading_order": 4 }, { "page": 1, "type": "LIST_ITEM", "location": { "l": 69.36, "t": 614.64, "r": 540.96, "b": 591.84 }, "text": "Collect the sample by masturbation into the sterile sample container provided by the Homerton Fertility Centre only. The container remains sterile until opened so avoid touching the inside.", "marker": "•", "list_id": "L1", "level": 0, "reading_order": 5 }, { "page": 1, "type": "LIST_ITEM", "location": { "l": 69.12, "t": 590.4, "r": 541.2, "b": 557.04 }, "text": "Ensure the entire sample is collected, especially the initial fraction which contains the most motile sperm. Do not attempt to recover any spillage, but please report it below. Replace the lid firmly immediately after collecting the sample.", "marker": "•", "list_id": "L1", "level": 0, "reading_order": 6 }, { "page": 1, "type": "LIST_ITEM", "location": { "l": 69.36, "t": 555.6, "r": 541.44, "b": 522 }, "text": "Do not use lubricant, water, hand creams or condoms when collecting the sample. Special condoms may be provided by the Homerton Fertility Centre for a £20.00 charge if required and by prior arrangement.", "marker": "•", "list_id": "L1", "level": 0, "reading_order": 7 }, { "page": 1, "type": "LIST_ITEM", "location": { "l": 69.36, "t": 520.56, "r": 541.68, "b": 497.76 }, "text": "After collecting onsite (Homerton Fertility unit), the sample must always be kept upright and placed in the inner pocket of the provided zip-lock specimen bag before being placed in the pass-through vault.", "marker": "•", "list_id": "L1", "level": 0, "reading_order": 8 }, { "page": 1, "type": "LIST_ITEM", "location": { "l": 69.36, "t": 496.56, "r": 541.44, "b": 450.96 }, "text": "After collecting off-site (at home), the sample must be brought to the Homerton Fertility Centre at your allocated appointment time and within 40 minutes from the time of production. During transportation the sample container should not be exposed to extreme temperatures, keep the sample upright and close to the body under your clothes.", "marker": "•", "list_id": "L1", "level": 0, "reading_order": 9 }, { "page": 1, "type": "LIST_ITEM", "location": { "l": 68.64, "t": 450.24, "r": 540.72, "b": 426.48 }, "text": "Do not produce your sample in a public area e.g. public toilets, car parks or anywhere else in the hospital - this is illegal (Sexual Offences Act 2003) and could result in prosecution.", "marker": "•", "list_id": "L1", "level": 0, "reading_order": 10 }, { "page": 1, "type": "TEXT", "location": { "l": 56.16, "t": 414.96, "r": 549.6, "b": 401.76 }, "text": "Please complete, sign, and return this form with your sample to the Homerton Fertility Centre.", "reading_order": 11 }, { "page": 1, "type": "TABLE", "location": { "l": 55.68, "t": 394.32, "r": 523.92, "b": 342.96 }, "text": "
Samples accompanied by incomplete/unsigned form will be rejected.
Routine semen analysisPost-vasectomy(Please tick as appropriate)
Repeat analysis? Yes / No, if yes, specify numberPrevious analysis location
", "rows": [ { "row_index": 0, "location": [ 55.68, 377.2, 523.92, 394.32 ], "cells": [ { "location": [ 55.68, 377.2, 523.92, 394.32 ], "text": "Samples accompanied by incomplete/unsigned form will be rejected.", "html_text": "Samples accompanied by incomplete/unsigned form will be rejected.", "links": [], "cell_header_index": 0, "rowspan": 1, "colspan": 3, "column_header": false, "row_header": false, "placeholder": false, "ref": "#/tables/0" } ], "ref": "#/tables/0" }, { "row_index": 1, "location": [ 55.68, 360.08, 523.92, 377.2 ], "cells": [ { "location": [ 55.68, 360.08, 211.76, 377.2 ], "text": "Routine semen analysis", "html_text": "Routine semen analysis", "links": [], "cell_header_index": 0, "rowspan": 1, "colspan": 1, "column_header": true, "row_header": false, "placeholder": false, "ref": "#/tables/0" }, { "location": [ 211.76, 360.08, 367.84, 377.2 ], "text": "Post-vasectomy", "html_text": "Post-vasectomy", "links": [], "cell_header_index": 1, "rowspan": 1, "colspan": 1, "column_header": true, "row_header": false, "placeholder": false, "ref": "#/tables/0" }, { "location": [ 367.84, 360.08, 523.92, 377.2 ], "text": "(Please tick as appropriate)", "html_text": "(Please tick as appropriate)", "links": [], "cell_header_index": 2, "rowspan": 1, "colspan": 1, "column_header": true, "row_header": false, "placeholder": false, "ref": "#/tables/0" } ], "ref": "#/tables/0" }, { "row_index": 2, "location": [ 55.68, 342.96, 523.92, 360.08 ], "cells": [ { "location": [ 55.68, 342.96, 211.76, 360.08 ], "text": "Repeat analysis? Yes / No, if yes, specify number", "html_text": "Repeat analysis? Yes / No, if yes, specify number", "links": [], "cell_header_index": 0, "rowspan": 1, "colspan": 1, "column_header": false, "row_header": false, "placeholder": false, "ref": "#/tables/0" }, { "location": [ 211.76, 342.96, 523.92, 360.08 ], "text": "Previous analysis location", "html_text": "Previous analysis location", "links": [], "cell_header_index": 1, "rowspan": 1, "colspan": 2, "column_header": false, "row_header": false, "placeholder": false, "ref": "#/tables/0" } ], "ref": "#/tables/0" } ], "n_rows": 3, "n_cols": 3, "ref": "#/tables/0", "reading_order": 12 }, { "page": 1, "type": "TABLE", "location": { "l": 37.44, "t": 325.68, "r": 574.32, "b": 164.88 }, "text": "
ForenameSurname
Date of BirthNHS ID
Days of AbstinenceTime of Production
Place of ProductionOnsite/OffsiteWas all the sample collected?Yes / No
Was there any difficulty in production?Yes / NoAny infection or inflammatory disease in last 6 months?Yes / No
a. I confirm that the specimen in the container is my semen sample and is correctly labelled with my name and D.O.B.
b. I confirm that all information provided is true and correct to the best of my knowledge.
c. Please tick as appropriate; I consent ☐ or I do not consent ☐ for any surplus specimen to be used for quality control and training purposes. All samples and data collected will be anonymised.
d. I confirm that I have read and understand the information provided in the patient information leaflet.
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"row_header": false, "placeholder": false, "ref": "#/tables/1" } ], "ref": "#/tables/1" }, { "row_index": 1, "location": [ 37.44, 289.9467, 574.32, 307.8133 ], "cells": [ { "location": [ 37.44, 289.9467, 171.66, 307.8133 ], "text": "Date of Birth", "html_text": "Date of Birth", "links": [], "cell_header_index": 0, "rowspan": 1, "colspan": 1, "column_header": false, "row_header": true, "placeholder": false, "ref": "#/tables/1" }, { "location": [ 171.66, 289.9467, 305.88, 307.8133 ], "text": "", "html_text": "", "links": [], "cell_header_index": 1, "rowspan": 1, "colspan": 1, "column_header": false, "row_header": false, "placeholder": false, "ref": "#/tables/1" }, { "location": [ 305.88, 289.9467, 440.1, 307.8133 ], "text": "NHS ID", "html_text": "NHS ID", "links": [], "cell_header_index": 2, "rowspan": 1, "colspan": 1, "column_header": false, "row_header": false, "placeholder": false, "ref": "#/tables/1" }, { "location": [ 440.1, 289.9467, 574.32, 307.8133 ], "text": "", "html_text": "", "links": [], "cell_header_index": 3, "rowspan": 1, "colspan": 1, "column_header": false, "row_header": false, "placeholder": false, "ref": "#/tables/1" } ], "ref": "#/tables/1" }, { "row_index": 2, "location": [ 37.44, 272.08, 574.32, 289.9467 ], "cells": [ { "location": [ 37.44, 272.08, 171.66, 289.9467 ], "text": "Days of Abstinence", "html_text": "Days of Abstinence", "links": [], "cell_header_index": 0, "rowspan": 1, "colspan": 1, "column_header": false, "row_header": true, "placeholder": false, "ref": "#/tables/1" }, { "location": [ 171.66, 272.08, 305.88, 289.9467 ], "text": "", "html_text": "", "links": [], "cell_header_index": 1, "rowspan": 1, "colspan": 1, "column_header": false, "row_header": false, "placeholder": false, "ref": "#/tables/1" }, { "location": [ 305.88, 272.08, 440.1, 289.9467 ], "text": "Time of Production", "html_text": "Time of Production", "links": [], "cell_header_index": 2, "rowspan": 1, "colspan": 1, "column_header": false, "row_header": false, "placeholder": false, "ref": "#/tables/1" }, { "location": [ 440.1, 272.08, 574.32, 289.9467 ], "text": "", "html_text": "", "links": [], "cell_header_index": 3, "rowspan": 1, "colspan": 1, "column_header": false, "row_header": false, "placeholder": false, "ref": "#/tables/1" } ], "ref": "#/tables/1" }, { "row_index": 3, "location": [ 37.44, 254.2133, 574.32, 272.08 ], "cells": [ { "location": [ 37.44, 254.2133, 171.66, 272.08 ], "text": "Place of Production", "html_text": "Place of Production", "links": [], "cell_header_index": 0, "rowspan": 1, "colspan": 1, "column_header": false, "row_header": true, "placeholder": false, "ref": "#/tables/1" }, { "location": [ 171.66, 254.2133, 305.88, 272.08 ], "text": "Onsite/Offsite", "html_text": "Onsite/Offsite", "links": [], "cell_header_index": 1, "rowspan": 1, "colspan": 1, "column_header": false, "row_header": false, "placeholder": false, "ref": "#/tables/1" }, { "location": [ 305.88, 254.2133, 440.1, 272.08 ], "text": "Was all the sample collected?", "html_text": "Was all the sample collected?", "links": [], "cell_header_index": 2, "rowspan": 1, "colspan": 1, "column_header": false, "row_header": false, "placeholder": false, "ref": "#/tables/1" }, { "location": [ 440.1, 254.2133, 574.32, 272.08 ], "text": "Yes / No", "html_text": "Yes / No", "links": [], "cell_header_index": 3, "rowspan": 1, "colspan": 1, "column_header": false, "row_header": false, "placeholder": false, "ref": "#/tables/1" } ], "ref": "#/tables/1" }, { "row_index": 4, "location": [ 37.44, 236.3467, 574.32, 254.2133 ], "cells": [ { "location": [ 37.44, 236.3467, 171.66, 254.2133 ], "text": "Was there any difficulty in production?", "html_text": "Was there any difficulty in production?", "links": [], "cell_header_index": 0, "rowspan": 1, "colspan": 1, "column_header": false, "row_header": true, "placeholder": false, "ref": "#/tables/1" }, { "location": [ 171.66, 236.3467, 305.88, 254.2133 ], "text": "Yes / No", "html_text": "Yes / No", "links": [], "cell_header_index": 1, "rowspan": 1, "colspan": 1, "column_header": false, "row_header": false, "placeholder": false, "ref": "#/tables/1" }, { "location": [ 305.88, 236.3467, 440.1, 254.2133 ], "text": "Any infection or inflammatory disease in last 6 months?", "html_text": "Any infection or inflammatory disease in last 6 months?", "links": [], "cell_header_index": 2, "rowspan": 1, "colspan": 1, "column_header": false, "row_header": false, "placeholder": false, "ref": "#/tables/1" }, { "location": [ 440.1, 236.3467, 574.32, 254.2133 ], "text": "Yes / No", "html_text": "Yes / No", "links": [], "cell_header_index": 3, "rowspan": 1, "colspan": 1, "column_header": false, "row_header": false, "placeholder": false, "ref": "#/tables/1" } ], "ref": "#/tables/1" }, { "row_index": 5, "location": [ 37.44, 218.48, 574.32, 236.3467 ], "cells": [ { "location": [ 37.44, 218.48, 574.32, 236.3467 ], "text": "a. I confirm that the specimen in the container is my semen sample and is correctly labelled with my name and D.O.B.", "html_text": "a. I confirm that the specimen in the container is my semen sample and is correctly labelled with my name and D.O.B.", "links": [], "cell_header_index": 0, "rowspan": 1, "colspan": 4, "column_header": false, "row_header": false, "placeholder": false, "ref": "#/tables/1" } ], "ref": "#/tables/1" }, { "row_index": 6, "location": [ 37.44, 200.6133, 574.32, 218.48 ], "cells": [ { "location": [ 37.44, 200.6133, 574.32, 218.48 ], "text": "b. I confirm that all information provided is true and correct to the best of my knowledge.", "html_text": "b. I confirm that all information provided is true and correct to the best of my knowledge.", "links": [], "cell_header_index": 0, "rowspan": 1, "colspan": 4, "column_header": false, "row_header": false, "placeholder": false, "ref": "#/tables/1" } ], "ref": "#/tables/1" }, { "row_index": 7, "location": [ 37.44, 182.7467, 574.32, 200.6133 ], "cells": [ { "location": [ 37.44, 182.7467, 574.32, 200.6133 ], "text": "c. Please tick as appropriate; I consent ☐ or I do not consent ☐ for any surplus specimen to be used for quality control and training purposes. All samples and data collected will be anonymised.", "html_text": "c. Please tick as appropriate; I consent ☐ or I do not consent ☐ for any surplus specimen to be used for quality control and training purposes. All samples and data collected will be anonymised.", "links": [], "cell_header_index": 0, "rowspan": 1, "colspan": 4, "column_header": false, "row_header": false, "placeholder": false, "ref": "#/tables/1" } ], "ref": "#/tables/1" }, { "row_index": 8, "location": [ 37.44, 164.88, 574.32, 182.7467 ], "cells": [ { "location": [ 37.44, 164.88, 574.32, 182.7467 ], "text": "d. I confirm that I have read and understand the information provided in the patient information leaflet.", "html_text": "d. I confirm that I have read and understand the information provided in the patient information leaflet.", "links": [], "cell_header_index": 0, "rowspan": 1, "colspan": 4, "column_header": false, "row_header": false, "placeholder": false, "ref": "#/tables/1" } ], "ref": "#/tables/1" } ], "n_rows": 9, "n_cols": 4, "ref": "#/tables/1", "reading_order": 13 }, { "page": 1, "type": "TEXT", "location": { "l": 37.44, "t": 153.6, "r": 575.52, "b": 139.98 }, "text": "Patient signature ________ Delivered by: ________ ( Write Full Name)", "reading_order": 14 }, { "page": 1, "type": "TEXT", "location": { "l": 37.44, "t": 139.98, "r": 575.52, "b": 126.36 }, "text": "LABORATORY USE ONLY", "reading_order": 15 }, { "page": 1, "type": "TEXT", "location": { "l": 37.44, "t": 126.36, "r": 575.52, "b": 112.74 }, "text": "Received by (Sign/initials)", "reading_order": 16 }, { "page": 1, "type": "TEXT", "location": { "l": 37.44, "t": 112.74, "r": 575.52, "b": 99.12 }, "text": "Time of receipt:", "reading_order": 17 }, { "page": 1, "type": "TEXT", "location": { "l": 107.52, "t": 83.28, "r": 494.88, "b": 56.16 }, "text": "For any queries, please contact the Homerton Fertility Centre on 02085107638 or email huh-tr.fertility.unit@nhs.net.", "links": [ { "uri": "mailto:huh-tr.fertility.unit@nhs.net", "dest": null, "action_type": "/URI", "bbox": [ 253.74, 57.602, 388.43, 70.251 ] } ], "reading_order": 18 } ] } ]