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For Physicians
Sexual Boost Questionnaire
Home
Sexual Boost Questionnaire
Sexual Boost
Step
1
of
39
2%
Name
(Required)
First Name
Family Name
Phone Number
Email
(Required)
Please answer these questions about your current medical status so that we can determine if a consultation with one of our physicians is necessary. Knowing this information will make the medical consultation maximally productive. Your answers to the questions will be kept confidential. If you are unsure how to answer or feel uncomfortable answering any of the questions you can skip over them.
Which of the following conditions apply to you at the moment:
I suffer from anxiety or stress.
Yes
No
Sometimes
My sexual relationships are lacking or problematic.
Yes
No
Sometimes
I lack confidence with my ability to perform sexually.
Yes
No
Sometimes
I have difficulty in arousal.
Yes
No
Sometimes
I have difficulty reaching orgasm.
Yes
No
Sometimes
I have problems with premature ejaculation.
Yes
No
Sometimes
I have pain during intercourse.
Yes
No
Sometimes
I have a concern about the size of my penis.
Yes
No
Sometimes
I lack energy.
Yes
No
Sometimes
I have a low libido or sex drive.
Yes
No
Sometimes
I sleep poorly.
Yes
No
Sometimes
I have concerns about how I/my body parts look.
Yes
No
Sometimes
GENERAL HEALTH HISTORY
Please indicate if you have any of the following health conditions:
Heart disease
Yes
No
Diabetes
Yes
No
Parkinson’s disease
Yes
No
Multiple Sclerosis (MS)
Yes
No
Have you had any back, neck, or spinal cord injuries
Yes
No
Do you have difficulty urinating?
Yes
No
Do you often get cold or numbness in your hands or feet?
Yes
No
Have you had a tumor or undergone surgery or radiation in the pelvic or genital region?
Yes
No
See what your erectile function score is
Click Here
Life style questionnaire:
What is your height? …….. Feet/Inch/cm
What is your weight? …….. lbs./Kg
What sort of exercise have you had in the past week? (select as many as apply)
Walking
Cycling
Swimming
Running
Team Sports
Weights
Other
No Physical Activity
In total, how many hours of exercise have you had in the past week?
0
1-2
3-4
5-6
7 or more
How many caffeinated beverages do you have per day, on average? (e.g., coffee, tea, or pop)
0-1
2-3
4-6
more than 6
How often do you have a drink containing alcohol?
Never
In the past
Monthly or less
2-4 times per month
2-3 times per week
4-6 times per week
Everyday
Do you smoke tobacco containing products?
Yes
No
How many years of smoking tobacco products do you have?
0
Less than 1
1-5
6-10
11-20
More than 20
How many cigarettes have you smoked per day during your smoking years in average?
0
1-4
5-10
11-20
21-30
30-40
more than 40
Have you ever used marijuana?
No
In the past
Using now
How many years in total have you used marijuana products?
0
Less than 1
1-5
6-10
11-20
More than 20
How long have you had difficulties with erections?
Less than one month
1-6 months
7-12 months
1-3 years
More than 3 years
How quickly did the problem start?
Gradually over years
Gradually over months
Over a few weeks
Suddenly
Over the last month when were you able to achieve an erection? (Select all that apply)
During foreplay
Immediately prior to intercourse
During intercourse
During other sexual activity
First thing in the morning
When alone
Over the last month, how many times have you attempted sexual intercourse?
No attempts
1-2 attempts
3-4 attempts
5-6 attempts
7-10 attempts
11 or more attempts
Over the last month, when you attempted sexual intercourse how often was it satisfactory for you?
No attempts
Almost never or never
A few times (much less than half the times)
Sometimes (about half the times)
Most times (much more than half the times)
Almost always or always
Over the last month, when you had sexual stimulation or intercourse, how often did you have an orgasm?
No attempts
Almost never or never
A few times (much less than half the times)
Sometimes (about half the times)
Most times (much more than half the times)
Almost always or always
Are you currently in a relationship and have a regular sex partner?
Yes
No
List of medications:
List the prescription medications you are taking currently or recently.
Add
Remove
List the naturopathic and herbal medicines you take regularly.
Add
Remove
List other over-the-counter, non-prescription medications you take regularly.
Add
Remove