Pre Consultation Form General

How did you hear about our clinic?

Last Name

First & Middle Names


City/Province/Zip/Post Code

Date of Birth

Email Address

Home Phone

Mobile Phone

Your Profession & Nationality

Please Note: Not all questions in this questionnaire are compulsory to answer, if there is a compulsory question that you did not answer, when you try to Submit the questionnaire you will see this warning message, **Please complete all required fields!** Scroll back up the page and look for the question highlighted in red.

(Please assign a numerical value from 1-7 to each goal in order of importance, with “1” being MOST important and “7” being LEAST important.)

Improved Energy

Improved Well Being

Weight Loss

Improved Sexual Function/Sex Drive

Improved Physical Stamina/Endurance/Strength

Management of Chronic Illness (Heart Disease, Type II Diabetes, Other)

<h3.How would you describe your general health?

Please indicate any serious conditions, illnesses or injuries, and any surgeries (including cosmetic), or hospitalizations; along with approximate dates:

Which medications, either by doctor’s orders or over the counter, are you taking, or have you taken in the past 6 months?

Please list, by name, any prescription medications, over-the-counter medications, and all vitamins/supplements/herbs you take regularly at this time. Include dosage if known.


Family History

Do you have a family history of any of the following diseases or conditions? When answering, include your parents, brother/sisters, and grandparents, if known.









Heart Disease


Kidney Disease

Mental Illness

Multiple Sclerosis



Review Of Systems:

Please Check any that apply

Ears, Nose, and Throat


Cardiovascular System

Hematology (Blood)


Gastrointestinal System

Neurological System

Genitourinary System

Musculoskeletal System

General Constitution

Integumentary (Skin) System





1. Have you ever had an abnormal PSA test or prostate exam?

If yes, please provide details if known (e.g. age, treatment, follow-up)

2. Do you have a family history of Prostate Cancer?

If yes, please provide details if known (e.g. relation, age of diagnosis, treatment)

3. Have you ever had any of the following? (Check all that apply and provide details)

Please provide details if known

4. Do you have or have you ever had Venereal Disease or any other STD?

International Index of Erectile Function (IIEF-5/SHIM)

Instructions: These questions ask about the effects your erection problems have had on your sex life. Please answer the following questions as honestly and clearly as possible. We understand the sensitive nature of these questions; therefore, all information is strictly confidential.

1. Over the past 6 months, how do you rate your confidence that you could keep an erection?

2. Over the past 6 months, when you had erections with sexual stimulation, how often were your erections hard enough for penetration (entering your partner)?

3. Over the past 6 months, during sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner?

4. Over the past 6 months, during sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?

5. Over the past 6 months, when you attempted sexual intercourse how often was it satisfactory for you?

International Prostate Symptom Score (IPSS)

Instructions: These questions ask about your urinary symptoms, OVER THE PAST 4 WEEKS


Incomplete Emptying:

Over the past month, how often have you had a sensation of not emptying your bladder completely after you finish urinating?


Over the past month, how often have you had to urinate again less than two hours after you finished urinating?


Over the past month, how often have you found you stopped and started again several times when you urinated?


Over the last month, how difficult have you found it to postpone urination?

Weak stream:

Over the past month, how often have you had a weak urinary stream?


Over the past month, how often have you had to push or strain to begin urination?


Over the past month, how many times did you most typically get up to urinate from the time you went to bed until the time you got up in the morning?

Quality of life due to urinary symptoms:

If you were to spend the rest of your life with your urinary condition the way it is now, how would you feel about that?

Prior Anabolic/Androgenic Steroid Use

**(Skip section if not applicable) **

1. Have you ever used anabolic steroids including Testosterone (either prescribed or not prescribed) anytime during your life?

4. Did you use Post Cycle Therapy (PCT) to restore your own testosterone production?

Male Reproductive:

Have you had any of the following symptoms?

Discharge or Sores?

Testicular masses?

Testicular pain?

Self-Testicular Exams?

Premature Ejaculation?

Male Patient History Questionnaire (check Yes or No)

Have you had any muscle weakness, fatigue or loss of muscle mass?

Has your interest in sex (libido) declined?

Do you have spontaneous erections (without medication or other aid)?

Have you experienced a decline in your energy levels or stamina?

Have you lost self-confidence, motivation or initiative?

Have you experienced a decline in memory or concentration ability?

Have you had any sleep disturbance or problems breathing while asleep?

Do you have mood swings or depression?

Have you noticed any increase in aggressiveness?

Do you have any breast tenderness or enlargement?

Has your need to shave decreased?

Have you noticed any significant change in the size of your testicles?

Do you have periodic hot flashes or sweats?

Have you ever had fertility problems (inability to have children)?

Are you considering having any (or more) children?

Social History (check Yes or No)

Do you use tobacco?

Did you use tobacco in the past?

Do you drink alcoholic beverages?

Coagulation Questionnaire

1.Do you have a FAMILY history of clotting (Deep Vein Thromhosis/DVT)/Pulmonary Embolism(PE): Stroke(CVA); Trans-Ischemic Attack(TIA); thrombosis in the artery?

Family history of venous thrombosis:

2.Have you had any previous episodes of clotting (Deep Vein Thrombosis/DVT)/Pulmonary Embolism(PE); Stroke(CVA); Trans-Ischemic Attack(TIA); thrombosis in the artery?

Personal History of venous thrombosis;

3.Are YOU a first-degree relative of someone with a PROVEN inherited clotting disorder?

Appointment Reminder Text/Email

May we send you a text message or email reminder the day before your appointment?
(We will not send you any other text messages or emails without prior approval.)

Sorry about this one, please prove you are not a Robot by adding the 5 characters above, exactly as they are shown, ie: UPPER or lower case.

Be sure to click Submit Questionnaire to send your results!

We will review your responses with you at your consultation, thank you for taking the time to complete this form.