Male Questionnaire - JS

Male Questionnaire

Pre-consultation Questionnaire
All male patients should complete this questionnaire before seeing any of our doctors at MySexualHealth.co.za.

The information you provide will remain fully confidential.

Please do not be offended by the nature of these questions. Since this is your first visit, we just want to make sure we have good background information. All patients answer exactly the same quesions, we do not imply anything by asking you these questions.

Where dates are requested, estimations are always appropriate.

Some fields are required and others not. If you do not complete a section that is not compulsory it will be assumed that you do not have a problem in this area or wish not to address it.

Contact Information
Name*

NameSurname
Date of birth*

DayMonthYear
Age
What is your occupation?

Hormones Replacement:
What form of Testosterone are you using?*

2.5% cream5% creamDepo Testosterone (2-3 weekly injection)PillsNebido (3monthly injection)
When was your last injection?

DayMonthYear

Pneumonia

YesNoI don't know
Varicella (Chicken Pox)

YesNoI had Chicken Pox as a child

Rectal Examination
Have you had a rectal examination before (where a doctor used his finger to check your prostate by gently inserting it into your anus)*

YesNo
When was your last rectal exam?*

DayMonthYear

Please write down anything else you would like to bring under your Doctor's attention:
Should be Empty: