EmailMe Form - Male Reproductive Health History Form

Name

Email

How was adolescence for you?

As a boy and young man, did you feel you had access to strong, enduring and compassionate male role models? If not, how do you feel about this?

What has been your experience of your own sexuality?

Do you have a history of sexual abuse? If yes, please elaborate at whatever level of detail you feel comfortable. If you ever received counseling for this, please describe your experience of the process.

Please select your current level of interest in sex.

High

Moderate

Low

Have you ever been diagnosed and/or treated for a sexually transmitted disease? If yes, please elaborate.

Are you a father? If yes, describe your involvement in and experience of pregnancy, birth and beyond?

Please select any symptoms relevant to you.

	Past	Present
Painful Urination
Urinary Retention
Urinary Incontinence or Dribbling
Difficulty Starting or Holding a Urine Stream
Weak or Interrupted Urine Flow
Blood or Pus in the Urine
Painful or Burning Urine
Pelvic Pressure
Frequent Noctural Urination
Insatiable Sex Drive
Lower Back Pain During Intercourse
Pain or Discomfort Between Scrotum and Testicles
Pain or Discomfort in Penis, Testicles or Rectum
Pain or Discomfort in Inner Thighs
Frequent Bladder or Kidney Infections
Difficulty Obtaining or Maintaing Erection
Painful Ejeculation

Are you currently on or have you previously taken medication for erectile dysfuction? If yes, please elaborate.

Have you had a vasectomy? If yes, please the date of the procedure and describe any symptoms/changes you have noticed since.

If you have taken the Prostate Specific Antigen (PSA) test, please provide the results and date of testing.

If you have had a Sperm Count Test done, please provide results and date of testing.

Is there a history of prostate disease in your family? If yes, please elaborate.

Is there a history of cancer in your family? If yes, please elaborate.