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HOME
- Accredited Compounding Pharmacy
LDN
CLINICAL TRIALS
MEN’S SEXUAL HEALTH
SERVICES
FORMS
- Physician Order Forms
- Men’s Sexual Health Video Resources (Printable)
SPECIALTIES
BLOG
CONTACT

Men’s Sexual Health Consultation Questionnaire

Fill out the form below to start improving your sexual health today.

This questionnaire is used during the Men’s Sexual Health Consultation
$150 (45 minutes), click here to schedule now

This questionnaire must be submitted 24 hours before your scheduled consultation.

SCHEDULE A CONSULTATION

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Name*
First Last
Email*
Phone*
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 Practice*
How Did You Find Us?*
- Google
- Social Media
- Other
Please specify*

1. Are you allergic to any medications?*
- Yes
- No
Please list allergies here:*
2. 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?*
- Yes
- No
5. Are you a current or former tobacco smoker?*
- Current
- Former
- Neither
6. Do you consume more than two (2) alcoholic beverages a day?*
- Yes
- No

7. Do you ever have a problem getting or maintaining an erection that is satisfactory for sex?*
- Yes
- Sometimes
- No
8. Are you able to achieve an erection via masturbation?*
- Yes
- Sometimes
- No
9. Are you able to climax?*
- Yes
- Sometimes
- No
10. Do you have a problem with premature ejaculation?*
- Yes
- No
- Sometimes
11. Do you get erections during the night (sleeping) or first thing in the morning?*
- Yes
- No
- Sometimes
12. How did your ED (erectile dysfunction) begin?*
- Suddenly and persistent
- Gradually, worsening over time

13. How long have you been dealing with your erectile dysfunction?*
14. Are you dealing with any urinary incontinence issues?*
- Yes
- No
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?*
- Yes
- No
17. 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 unchanged
- I do not think about sex because I cannot achieve an erection
- I do not think about sex, I have no interest, sex drive is not normal
18. What best describes your energy level?*
- Always energetic
- Normal, consistent energy level
- Energy level has decreased
- Always fatigued
19. Describe your exercise habits:*
- 5 or more times a week
- 2-3x a week
- Rarely
- Never

20. Have you had your hormone levels tested?*
- Yes
- No
When were they tested?*
Date: Results:
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 medication
- Never had side effects with ED medication
- Yes, list medication and side effect
Please list medication and side effect here:*
24. Have you ever used a Vacuum Erection Device (penile pump)?*
- Yes
- No
25. What are your intimacy goals, i.e. duration, pleasure, etc.?*
26. What specific questions do you have for the pharmacist?*

DO YOU HAVE A QUESTION FOR A PHARMACIST?

Location

535 East Crescent Ave
Ramsey, NJ 07446

Contact

(201) 447-2020
Toll Free: 800-850-2101
(201) 447-3253
info@tccompound.com

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