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

Name*
First Last
Email*
Phone*
Date of Birth*
Month
Day
Year
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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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

DO YOU HAVE A QUESTION FOR A PHARMACIST?

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