Patient Consultation Form Home > Men’s Health > Men’s Sexual Health Consultation Questionnaire Men’s Sexual Health Consultation Questionnaire Fill out the form below to start improving your sexual health today. 1 2 3 4 5 First Name*Last Name*Email* Phone Number*Date of Birth* MM DD YYYY 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 PracticeHow Did You Find Us? Google Social Media Other Please Specify 1. Are you allergic to any medications?*YesNoPlease list allergies here2. List all current medications you are taking:3. 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:4. Do you have a family history of heart disease?*YesNo5. Are you a current or former tobacco smoker?*CurrentFormerNeither6. Do you consume more than two (2) alcoholic beverages a day?*YesNo 7. Do you ever have a problem getting or maintaining an erection that is satisfactory for sex?*YesSometimesNo8. Are you able to achieve an erection via masturbation?*YesSometimesNo9. Are you able to climax?*YesSometimesNo10. Do you have a problem with premature ejaculation?*YesSometimesNo11. Do you get erections during the night (sleeping) or first thing in the morning?*YesSometimesNo12. How did your ED (erectile dysfunction) begin?*Suddenly and persistentGradually, worsening over time 13. How long have you been dealing with your erectile dysfunction?*14. Are you dealing with any urinary incontinence issues?*YesNoHow are you dealing with your urinary incontinence? Check all that apply. Pads/Protective Garments Pelvic Floor Muscle Exercises Clamp Device Medication Catheter Other Please describe.15. Did your ED begin due to surgery, injury, or new medication?* Surgery Injury New medication None of the above 16. Did your ED begin with a new partner?*YesNo17. 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 unchangedI do not think about sex because I cannot achieve an erectionI do not think about sex, I have no interest, sex drive is not normal18. What best describes your energy level?*Always energeticNormal, consistent energy levelEnergy level has decreasedAlways fatigued19. Describe your exercise habits:*5 or more times a week2-3x a weekRarelyNever 20. Have you had your hormone levels tested?*YesNoWhen were they tested?21. 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 None, never attempted therapy 22. 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 None, never attempted therapy 23. Did you experience any side effects when using any ED medications?*Never taken ED medicationNever had side effects with ED medicationYes, list medication and side effectPlease list medication and side effect here:24. Have you ever used a Vacuum Erection Device (penile pump)?*YesNo25. What are your intimacy goals, i.e. duration, pleasure, etc.?*26. What specific questions do you have for the pharmacist?
