Confidential Professional Assessment

Professional Male Sexual & Whole-Body Health Assessment

A structured health questionnaire designed to understand your sexual health concerns together with relevant cardiovascular, metabolic, hormonal, neurological, nutritional, digestive and lifestyle factors.

Section 1 of 12 8%

Personal & Relationship Profile

These details help us understand your general profile and the context surrounding your health concerns.

1. Full Name *

2. Age *

3. Sex *

4. Height (cm) *

5. Weight (kg) *

6. Region / Country of Residence *

7. Phone / WhatsApp Number *

8. Email Address *

9. Marital Status

Married Single Separated Divorced Widowed Prefer not to say

Primary Sexual Health Concern

Please describe the main concern that led you to request this assessment.

10. What is your primary concern? *

11. What other concerns are you experiencing?

Reduced sexual desire/libido Difficulty getting or maintaining an erection Premature ejaculation Losing an erection during sexual activity Reduced sensation Other concern

12. How long have you experienced this concern? *

13. How did the problem begin? *

Suddenly Gradually It comes and goes

14. How frequently does the problem occur? *

Erection, Libido & Sexual Function

These questions help characterize sexual function without assuming a specific underlying cause.

15. How has your sexual desire changed? *

16. How would you describe erection firmness? *

Firm and lasts well I can get an erection, but it sometimes becomes less firm The erection is weak I cannot get an erection

17. Do you get an erection but lose it quickly? *

18. Do you experience morning erections?

19. Have you noticed changes in sexual sensation?

20. Do you experience difficulty reaching orgasm or ejaculation?

21. Do you experience pain during or after sexual activity? *

No Yes, during sexual activity Yes, after sexual activity Yes, during and after

22. If you experience pain, describe the location and nature.

Sexual & Masturbation History

This section is included as part of the overall sexual history. Answer only what you are comfortable sharing.

23. Have you ever masturbated? *

Yes No Prefer not to say

24. Approximately how long has masturbation been part of your sexual history?

25. How frequently do you currently masturbate?

26. Do you believe your sexual history may be relevant to your current concern?

27. Have you noticed any change in sexual response when masturbating less frequently or stopping?

No noticeable change Change in sexual desire Change in erection response Change in orgasm response Other change Not sure

28. Do you feel your sexual history has affected any of the following?

Sexual desire Erection quality Ability to reach orgasm Sexual satisfaction No noticeable effect Not sure

29. Is there anything else about your sexual history you believe is relevant?

Penis, Testicular, Urinary & Prostate Health

30. What concerns do you have regarding your testicles?

Pain Heaviness or pulling sensation Swelling Lump or unusual swelling Other noticeable change No concern

31. Have you noticed any changes in your penis?

Change in shape New or worsening curvature Pain Change in sensation No changes

32. Do you experience numbness or reduced genital sensation?

33. Difficulty starting urination?

34. Weak or interrupted urine stream?

35. Frequent urination, especially at night?

36. Burning or pain during urination?

37. Blood in urine? *

38. Have you ever been diagnosed with a prostate problem?

Cardiovascular & Metabolic Health

Erectile and sexual health can sometimes occur alongside cardiovascular and metabolic risk factors. This section helps identify relevant history.

39. Have you been told that you have high or low blood pressure? *

40. Have you ever taken blood pressure medication?

41. Do you have diabetes or prediabetes? *

42. Have you had your blood sugar checked recently?

43. If known, enter your most recent blood sugar or HbA1c result.

44. Have you been diagnosed with high cholesterol or abnormal blood lipids?

45. Do you experience chest discomfort, unusual breathlessness, palpitations or rapid heartbeat?

Chest discomfort Unusual breathlessness Palpitations Rapid heartbeat None

46. Have you ever been diagnosed with heart disease or another cardiovascular condition? *

Nervous System & Neurological Symptoms

47. Do you experience numbness, tingling or pins-and-needles?

48. Where do you experience these sensations?

Feet Hands Legs Arms Back Genital area Other

49. Do you experience burning sensations in your hands or feet?

50. Do you experience unexplained weakness or reduced strength?

51. Do you experience dizziness or balance problems?

52. Have you noticed significant changes in memory, concentration or mental alertness?

53. Do you experience persistent headaches?

Hormonal, Vitamin & Mineral Risk Factors

Symptoms alone cannot confirm a vitamin, mineral or hormone deficiency. The information below helps identify areas that may warrant appropriate laboratory assessment.

54. Have you ever been told that you have low testosterone or another hormone problem?

55. Have you ever been diagnosed with a thyroid condition?

56. Have you experienced unexplained tiredness or low energy?

57. Do you frequently experience muscle cramps or unusual muscle weakness?

58. Do you have dietary restrictions that may limit nutrient intake?

Vegetarian Vegan Food intolerance Poor appetite Other restricted diet None

59. Have you ever been told you have low iron, vitamin B12, vitamin D, folate, calcium, magnesium or another nutrient?

60. If known, which nutrient was reported low?

Kidney, Liver & Digestive Health

61. Do you have kidney or liver problems? *

62. Do you experience persistent stomach or digestive symptoms?

Bloating Excessive gas Constipation Diarrhea Abdominal discomfort History of ulcers None

63. Have you ever had surgery?

64. Do you experience unexplained changes in appetite or digestion?

Medication, Allergies & Infection History

65. Are you currently taking prescribed medication? *

66. If yes, list the medication names and reason for use.

67. Do you use vitamins, supplements, herbal products or other non-prescription products? *

68. If yes, list the product names and how often you use them.

69. Do you have any known allergies to medicines, foods, herbs or supplements? *

70. If yes, describe the substance and reaction.

71. Have you ever been diagnosed with a sexually transmitted infection? *

72. Do you currently have genital discharge, sores, ulcers, unusual rash or burning during urination? *

73. If yes, describe the symptoms.

Sleep, Stress, Nutrition & Lifestyle

74. How would you describe your sleep?

I generally sleep well I usually sleep very late I frequently struggle to sleep I snore I feel excessively sleepy during the day

75. Do you experience significant stress?

76. How many meals do you normally eat per day?

77. Describe your typical daily diet.

78. Approximately how much water do you drink per day?

79. Do you exercise?

80. Do you use tobacco or cigarettes? *

81. Do you consume alcohol? *

Medical Tests, Documents & Final Information

If you have recent medical information that is relevant to your concern, you may provide it here for consideration as supporting information.

82. Have you previously consulted a healthcare professional about this concern? *

83. Have you previously used medication or another treatment for this concern? *

84. If yes, provide the name of the treatment or medication if known.

85. Have you had recent laboratory or medical tests?

86. If yes, list any results you know.

Medical Documents & Test Results

You may upload relevant laboratory results, medical reports, prescriptions or scan reports.

Accepted formats: PDF, JPG, JPEG and PNG. Only upload documents relevant to your own assessment.

87. Is there anything specific you would like us to pay attention to in the uploaded documents?

88. Describe any other important symptoms or health concerns not covered above.

89. What type of professional guidance are you hoping to receive?

Professional Assessment Notice

Your answers are intended to provide structured background information for professional review. Symptoms and questionnaire responses alone cannot confirm a diagnosis or establish a vitamin, mineral, hormone or neurological deficiency. Where appropriate, further clinical assessment or laboratory testing may be recommended.

Before You Submit

Please review your name, email address, telephone number, medical history, medications, allergies, symptoms and uploaded documents carefully. Accurate information helps ensure that the assessment is based on the information you intended to provide.

I confirm that the information I have provided is accurate and complete to the best of my knowledge, and I consent to its use for the purpose of reviewing my health assessment and providing appropriate professional guidance. *

Important

This assessment does not replace an in-person medical examination, diagnosis or emergency medical care. If you have severe or rapidly worsening symptoms, seek appropriate medical attention promptly.

Final Review

You have reached the final section. Please make sure your information is correct before selecting SUBMIT ASSESSMENT.

After submission, your information will be sent for professional review.

Confidential Health Information
Please provide only information relevant to your assessment. Your information is intended for the purpose stated in this form.