Male Questionnaire - ER

  • Male Questionnaire

    Pre-consultation Questionnaire for Dr. Elna Rudolph

  • Dear patient,

    Thank you for taking the time to complete this questionniare.  I will make the time spent with me during your consulation much more effective. I suggest that all biologically male patients complete this questionnaire before they see me.

    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.

    I am looking forward to meeting you soon and helping you to "love life with confidence"!

    Kind regards

    Dr. Elna Rudolph

  • Contact Information

  • Gender

  • Sexual History

  • Please indicate your current relationship status:
  • Do you have sex without condoms?
  • What is your sexual orientation
  • Are you concerned about having a possible sexually transmitted infection?
  • Please indicate if you have ever had one or more of the following infections:
  • Are you using hormone replacement therapy in the form of Testosterone?

  • Hormones Replacement:

  • What form of Testosterone are you using?*

  • Sexual Dysfunction

  • Are you concerned about having a low sex drive?
  • Do you struggle to get or maintain an erection?
  • Are you concerned about ejaculating too early (not lasting long enough?)
  • Are you concerned about taking too long to ejaculate or not being able to achieve an orgasm?
  • If you completed the AMS (Ageing Male Symptom Score), what was your result?
  • Do you experience bothersome pain in your pelvis or genitals?

  • Erectile Dysfunction:

  • INTERNATIONAL INDEX OF ERECTILE FUNCTION (IIEF-5) QUESTIONNAIRE

    This is a standardised questionnaire to determine your erectile function.  Please answer these questions about your erectile function during the PAST SIX MONTHS:

  • How do you rate your confidence that you can get and keep and erection?
  • When you had erections with sexual stimulation, how often were your erections hard enough for penetration?
  • During sexual Intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partnet?
  • During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?
  • When you attempted intercourse, how often was it satisfactory for you?
  • Will you please add up the scores of the previous 5 questions to answer the following question?
  • What did you score in the IIEF-5?
  • Please indicate which of these treatments for erectile dysfunction you have used in the past AND have worked well for you
  • Please indicate which of these treatments for erectile dysfuntion you have used without the desired effect

  • Are you and your partner currently trying to have a baby?

  • Fertility History

  • Would you like to have more children in the foreseeable future?
  • Have you been struggling to concieve for more than one year?
  • Have you had a semen analysis?

  • Medical conditions

    Please indicate which of these conditions you are currently suffering from or if you have suffered from it in the past
  • Allergies?*
  • High Blood pressure?*
  • Angina (The condition where you get a sharp pain in your heart when you become out-of-breath or sometimes even spontaneously)*
  • Heart Failure*
  • High Cholesterol
  • Diabetes
  • Depression
  • Anxiety
  • Severe Stress
  • Testicular Cancer
  • Prostate Cancer*
  • Family History of Prostate Cancer*
  • Sleep Apnoea (Severe snorring where you sometimes stop breathing for a few seconds)*
  • Abnormal discharge from your penis?
  • Any sores or growths on your genitals?
  • Constipation
  • Any problems with passing urine, burning urine, leaking urine, getting up at night to urinate, dribbling or any other problem with your bladder?
  • Frequent and bothersome abdominal pain?

  • Lifestyle

  • Do you smoke?
  • Have you used any recreational drugs in the last year?
  • How many units of alcohol do you use per week? (One unit equals a small glass of wine, a small bottle of beer or one tot of hard liquor)
  • Do you get 30 minutes of exercise five times a week (or the equivalent)?

  • 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)*
  •  - -

  • Medical Examinations

  • Please inidcate which of the following medical examinations you have had in the last two years: (please tick the test as well as "normal" or "abnormal" for all the test that you have had)
  • Should be Empty: