Male Intake Form

TheBox:V'Jinga: Men's Health Questionnaire

As men age, it is common to develop prolonged sexual and/or bladder health conditions and to have questions about these important quality of life health conditions. Complete this questionnaire to assess your sexual and/or bladder health. If needed, treatments are available for you.

Name *

Date

My Urologist/Primary Care Provider

Sexual Health Inventory for Men (SHIM¹

Answer the sexual health questions by inputting your answer and adding up your score.

1) How do you rate your confidence that you could get and keep an erection?

Very Low - Put the Number 1 below

Low - Put the Number 2 below

Moderate - Put the Number 3 below

High -Put the Number 4 below

Very High - Put the Number 5 below

2) When you had erections with sexual stimulation, how often were your erections hard enough for penetration?

Almost never or never - Put the Number 1 below

A few times - Put the Number 2 below

Sometimes - Put the Number 3 below

Most times - Put the Number 4 below

Almost always or always - Put the Number 5 below

3) During sexual intercourse, how often were you able to maintain your erection after you had penetrated

Almost never or never - Put the Number 1 below

A few times - Put the Number 2 below

Sometimes - Put the Number 3 below

Most times - Put the Number 4 below

Almost always or always - Put the Number 5 below

4) During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?

Extremely difficult - Put the Number 1 below

Very difficult - Put the Number 2 below

Difficult - Put the Number 3 below

Slightly difficult - Put the Number 4 below

Not difficult - Put the Number 5 below

5) When you attempted sexual intercourse, how often was it satisfactory for you?

A few times - Put the Number 2 below

Sometimes - Put the Number 3 below

Most times - Put the Number 4 below

Almost always or always - Put the Number 5 below

Add the numbers above and enter your Total Score Below

The Sexual Health Inventory for Men (SHIM) classifies ED severity with the following breakpoints:

1-7: Severe ED 8-11: Moderate ED 12-16: Mild/Moderate ED 17-21: Mild ED 22-25: No ED

6 Check any ED treatments you have tried

Pills/Medication Vacuum Device Injection Therapy MUSETM Other

Please provide any additional information that you would like to discuss at your appointment: (Optional)

2) Do you experience urine leakage? If "YES", proceed to the next question. If "No", disregard this assessment. *

Yes No

3) Which symptoms best describe you?

Leakage with little or no warning sometimes unable to make it to the bathroom in time Frequent Urination ( day, night, or both) Accidental leakage with physical activity (e.g., exercising) Other ( If you choose this option,then please indicate further information below

Please explain below

4) Do you wear pads or diapers, use a urine collection device or a penile clamp?

Other Pads: how many per day Diapers: how many per day Urine collection device Penile clamp

5) On a scale of 0 to 5, with 0 being no bother and 5 being extreme bother, how bothered are you by your bladder control? *

List all Medical Conditions

List all Medications

I understand that lingam steaming may have positive or negative side effects as a result of doing a steam session. I accept legal responsibility for my choice to do a lingam steam session and waive the responsibility of the practitioner and the facility where the steam session takes place in the case that any of the named side effects (or others) may occur.

Photography, filming, and podcasts disclaimer:

Please note that photographs and footage will be taken at any thebox:V'Jinga events. These will be used by thebox: V'Jinga for marketing and publicity in our publications, on our website and in social media, or in any third-party publication. Please contact the company if you have any concerns or if you wish to be exempted from this activity.

FINANCIAL POLICY
Thank you for choosing us for services. We are committed to providing you with the
best possible atmosphere and experience at the lowest possible cost. The following is our Financial Policy that we require you to read and sign.
Full payment for services is due at time of appointment. We accept cash, checks (with ID) or Visa/MasterCard, Cashapp. There will be a charge of $50 for returned checks and future checks will not be accepted.
The first visit, steam is $65.00. This steam is usually 15 minutes to ensure your body doesn’t have any negative reactions to the herbs or the steaming process. Follow up steams are $45.00 and last 30 minutes. We also have packages available to give you a better value for the service.
See your steam facilitator for pricing options for the packages.
In order to keep our fees to a minimum, a deposit is due now and the remaining balance is required at the time of service.

For unaccompanied minors, non-emergency treatment will be denied unless charges have been preauthorized to a Visa/MasterCard or payment by cash or check.

This information is stored in a password protected computer and would only be charged in the event of a No-Show or late cancellation with less than 4-hour notice.

Please give us 4-hour notice in advance if you cannot keep your appointment for any reason.
The deposit is nonrefundable for No-Show/late cancellation for all services. This policy will be enforced.

Signature

Clear

Recommended Blend

Cloak or No Cloak

Steam Schedule and Notes

For Facilitator Use ONLY:

Male Lingam FACT SHEET