Sexual Health Questionnaire Form

What are you looking to treat? *Erectile dysfunctionPremature ejaculationBoth

Please include your information

First Name *

Last Name *

Phone number *

Email Address *

What is your date of birth?

Day

Month

Year

What was your sex at birth? *MaleFemale

What is your height in cm? *

What is your weight in kg? *

Lifestyle

Do you smoke? *NoYesRarely

How long have you been smoking for and how many cigarettes per day? *

Do you use any recreational drugs? *YesNo

What recreational drugs do you use? *

How often do you drink alcohol? *Not at allRarelyLess than two standard drinks per dayMore than two standard drinks per day

How often do you exercise? *3-5 times per week2-3 times per weekOnce a weekNot a priority

How would you describe your diet? *Very healthy, I'm all over the latest diet trendsPretty healthy but could do with improvementNot very healthy - I love my Maccas and 'PortosDon't care for healthy food - celery is the devil

How would you rate your average nights sleep? *(5 stars = Excellent 1 star = Very bad)

How would you rate your mood recently? *(5 stars = Excellent 1 star = Very bad)

Medication History

Do you have any allergies? *YesNo

What allergies do you have? *

Have you ever taken or used any medications or supplements for premature ejaculation before? *YesKind of, I’ve dabbledNo

Please note the name of the medication, dosages and effectiveness.(If you can't remember right now, please continue and the doctor will follow up later.)

Are you currently taking any medications, supplements or herbs? *YesNo(Important (your life depends on it): ED tablets and nitrate medications such as GTN spray, GTN tablets or GTN patches can cause a fatal reaction. Glyceryl Trinitrate and other drugs that alter your heart rate can have fatal consequences. You must not take ED medication if you take a GTN spray (such as Nitrolingual), tablets (such as Nicorandil or Nitrostat), patches (such as Transiderm or Minitran), GTN gels or creams. See your regular GP to discuss alternative options if you are unsure. Please confirm that you understand and have disclosed all medications you are taking.)

What medications or supplements do you currently use? *(Please state the name of the medication, dosages and effectiveness. If you can't remember right now, please continue and the doctor will follow up later.)

Medical Conditions

Do you ever experience any of the following symptoms when passing urine? *Problems with starting or stopping your streamGoing more than you used to, especially at nightInterrupted stream - stopping/starting/dribblingUrge to go more often and less ability to hold onNone(Please select all that apply.)

Do you suffer from any of these? *Peyronie's disease (a curve in the penis that interferes with sex)Painful erections or ejaculationForeskin that is too tightAny other abnormality of the penisNone

Are you able to walk 1km in 15 minutes on the flat, and climb two flights of stairs in 10 seconds without chest discomfort, pain or undue breathlessness? *YesNo

Do you frequently get dizzy if you stand up suddenly? *YesNo

Family History

Is there a history of any other medical illness or disorder that has run within your family? *YesNo

Please explain the medical illness that has run within your family. *(NOTE: Would you like to add any other information that you find might be helpful to share with your doctor?)

Telehealth Services .

Needing assistance?

info@treatclinic.com.au