Men Sexual Wellness Questionnaire
Name
*
First Name
Last Name
Birthdate:
*
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Marital Status
*
SINGLE
MARRIED
DIVORCED
WIDOWED
SEPERATED
I AM INTERESTED IN THE FOLLOWING:
*
TESTOSTERONE REPLACEMENT THERAPY
TRI-MIX
PRIAPUS SHOT
NOT SURE
DO YOU HAVE ANY OF THE FOLLOWING:
*
YES
NO
ERECTILE DYSFUNCTION
DECREASED LIBIDO (SEX DRIVE
BRAIN FOG/DECREASED MENTAL CLARITY
LOSS OF MEMORY/DECREASED ENERGY
DEPRESSION
ANXIETY
IRRITABILITY
TROUBLE SLEEPING/INSOMNIA
DECREASED SELF CONFIDENCE
LOW MOTIVATION
WEIGHT GAIN/INCREASED BODY FAT
BONE LOSS/DECREASED BONE DENSITY
DECREASED MUSCLE MASS/STRENGTH
HARDER TO BUILD/MAINTAIN MUSCLE
DECREASED EXERCISE TOLERANCE/LONGER RECOVERY TIME
ALLERGIES?
*
ARE YOU CURRENTLY ON ANY TESTOSTERONE REPLACEMENT THERAPY?
*
HAVE YOU EVER USED TESTOSTERONE REPLACEMENT THERAPY?
*
HAVE YOU HAD YOUR PROSTATE REMOVED?
*
DO YOU HAVE ANY HISTORY OF ANY KIND OF CANCER?
*
DO YOU HAVE A HISTORY OF BLOOD CLOTS?
*
DO YOU STRUGGLE WITH ANY OF THE FOLLOWING:
*
ISSUES WITH AROUSAL
ISSUES WITH STAMINA
SOFT ERECTIONS
DECREASED SENSITIVITY
PAIN WITH ERECTION
PENUS CURVATURE
UNHAPPY WITH PENIS LENGTH/GIRTH
NONE OF THE ABOVE
OTHER
DO YOU HAVE ANY MEDICAL PROBLEMS? IF SO LIST THEM?
*
HAVE YOU BEEN HOSPITALIZED IN THE LAST YEAR? IF SO FOR WHAT?
*
DO YOU HAVE A FAMILY HISTORY OF CANCER OF THE BREAST, OVARIAN, COLON, OR PANCREAS?
*
WHAT MEDICATION DO YOU TAKE?
*
DO YOU HAVE SLEEP APNEA?
*
WHY ARE YOU SEEKING TREATMENT?
*
ARE YOU IN GOOD HEALTH?
*
WHEN WAS YOUR LAST HEALTH CHECKUP?
*
WHAT IS THE NAME AND CONTACT INFORMATION OF YOUR EMERGENCY CONTACT?
*
DO YOU TAKE ANY OF THE FOLLOWING:
*
SILDENAFIL (VIAGARA)
TADALAFIL (CIALIS)
AVANAFIL (STENDRA)
VARDENAFIL (LEVITRA)
OTHER
NONE
ANYTHING YOU WANT US TO KNOW?
Today's Date
*
-
Month
-
Day
Year
Date
Signature
*
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