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Sexual Questionnaire


Name:
Email:
Phone:
Zip Code:
Marital Status

Describe your current sexual problems. If your problem is with erections, do you have more trouble getting an erection, maintaining an erection, or both.
Do you have a steady sexual partner?
Yes No Other - Explain :
When did your current sexual problems begin?
sudden gradual Other - Explain :
Why do you think you are having sexual problems?
Psychological Physical
When was the last time you had successful intercourse?
Are (or were) your erections straight or curved?
straight curved
Are (or were) erections painful?
Describe your sex life before your current problem.
Describe any treatment you had had for this problem and include names and addresses of the persons who have treated you.
Do you get firm erections under any of the following conditions:
Early morning/awakening from sleep Yes No N/A
With the need to urinate Yes No N/A
Manual stimulation - self Yes No N/A
Manual stimulation - partner Yes No N/A
Oral stimulation Yes No N/A
Anal sex Yes No N/A
Female partner, other than spouse Yes No N/A
Male partner Yes No N/A
Erotic clothing on self or partner Yes No N/A
Vacation times Yes No N/A
Unusual places other than bedroom Yes No N/A
Erotic books, magazines, videos Yes No N/A
Are erections ever sufficient for vaginal intercourse Yes No N/A
Do you lose erections during intercourse Yes No N/A
Do you lose erections before ejaculation Yes No N/A
Are you still able to have an orgasm (ejaculate) Yes No N/A
Does semen come out of your penis normally Yes No N/A
How would you rate your sex drive or libido or desire on a scale from 1-10
Do you have any of the follow conditions
Diabetes Yes No
Hypertension (high blood pressure) Yes No
Nervous condition Yes No
Thyroid problems Yes No
Cancer Yes No
Chronic pain Yes No
Back problems Yes No
Poor circulation Yes No
Difficulty urinating Yes No
Constipation Yes No
Leg or calf pain with walking Yes No
Have you ever had any surgery on your:
Back Yes No
Rectum Yes No
Blood vessels Yes No
Have you ever seen a psychotherapist about this or any other problem Yes No
If yes, please explain the situation
How much alcohol do you consume?
types
amounts
frequency
For how many years?
How many packs of cigarettes do you smoke in an average day?
How long have you smoked?
If you have stopped smoking, how long have you been a non-smoker?
How does your sexual partner view your problem?
Do you talk about it? Yes No
Are there problems brewing because of the sexual problem? Yes No
What treatment plans have you heard about?
Psychological counseling Yes No
Penile implants Yes No
Hormone injections Yes No
Vacuum pumps Yes No
Urethral suppositories Yes No
Yohimbine Yes No
How old were you when you became sexually active with partners?
Have you ever been sexually abused? Yes No

Add any information that you believe to be helpful and fill out the other general information sheets.
Important note: Many insurances DO NOT cover expenses for treatment of sexual dysfunction. Please refer to your Benefit Guide under exclusions or call your insurance company for information regarding coverage. If your insurance company does not provide coverage, YOU will be responsible for payment.

Contact form

Your first name:

Zip codes:

Email:

Phone:

Procedures:

Security Code:
Are you suffering from Sexual Dysfunction?

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