Men’s Sexual Health Consultation Questionnaire
Fill out the form below to start improving your sexual health today.
Name
*
First Name
Last Name
Email
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
Preferred Method Of Contact (Check All That Apply)
Phone Call
Text
Email
Were You Referred By A Health Care Professional?
Yes
No
Please List Physician Name and Practice
How did you find us?
Google
Social Media
Others
Please Specify
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1. Are you allergic to any medications?
Yes
No
Please list allergies here
2. List all current medications you are taking
3. Please list any vitamins / herbal supplements that you are taking
4. Do you have any of these medical conditions?
High blood pressure
Heart disease
Depression
Diabetes
High Cholesterol
None of the above
Other, list below
Other medical condition:
5. Do you have a family history of heart disease?
Yes
No
6. Are you a current or former tobacco smoker?
Current
Former
Neither
7. Do you consume more than two (2) alcoholic beverages a day?
Yes
No
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8. Do you ever have a problem getting or maintaining an erection that is satisfactory for sex?
Yes
Sometimes
No
9. Are you able to achieve an erection via masturbation?
Yes
Sometimes
No
10. Are you able to climax?
Yes
Sometimes
No
11. Do you have a problem with premature ejaculation?
Yes
Sometimes
No
12. Do you get erections during the night (sleeping) or first thing in the morning?
Yes
Sometimes
No
13. How did your ED (erectile dysfunction) begin?
Suddenly and persistent
Gradually, worsening over time
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14. How long have you been dealing with your erectile dysfunction?
15. Are you dealing with any urinary incontinence issues?
Yes
No
16. Did your ED begin due to surgery, injury, or new medication?
Surgery
Injury
New medication
None of the above
17. Did your ED begin with a new partner?
Yes
No
18. Some therapy is based on your sex drive or libido, which best describes you?
Think about sex, want to have sex, drive is normal or unchanged
I do not think about sex because I cannot achieve an erection
I do not think about sex, I have no interest, sex drive is not normal
19. What best describes your energy level?
Always energetic
Normal, consistent energy level
Energy level has decreased
Always fatigued
20. Describe your exercise habits:
5 or more times a week
2-3x a week
Rarely
Never
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21. Have you had your hormone levels tested?
Yes
No
What is your testosterone level?
22. Which of the following ED medications have you tried? Select all that are applicable:
Sildenafil (Viagra, Revatio)
Tadalafil (Cialis, Adcirca)
Vardenafil (Levitra)
Avanafil (Stendra)
Caverject, Edex
MUSE
Bi-Mix
Tri-Mix
Quad-Mix
None, never attempted therapy
23. If you have tried ED medications in the past which one(s) worked best for you? This can include medications you are no longer taking.
Sildenafil (Viagra, Revatio)
Tadalafil (Cialis, Adcirca)
Vardenafil (Levitra)
Avanafil (Stendra)
Caverject, Edex
MUSE
Bi-Mix
Tri-Mix
Quad-Mix
None, never attempted therapy
24. Did you experience any side effects when using any ED medications?
Never taken ED medication
Never had side effects with ED medication
Yes, list medication and side effect
Please list medication and side effect here:
25. Have you ever used a Vacuum Erection Device (penile pump)?
Yes
No
26. What are your intimacy goals, i.e. duration, pleasure, etc.?
27. What specific questions do you have for the pharmacist?
Submit
Should be Empty: