| Brief Personal History - For Men | |
| Name:__________________________________ Phone Number___________________ | |
| Address:________________________________ | |
| DOB__________________ Place of Birth___________________ Highest level of Education__________ | |
| Where did you grow up____________________________________________________ | |
| Height______________ Weight_____________ Brothers and Sisters____________________________ | |
| Medical Problems:
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| Prescription Medications (Name, Dose, number of times taken per day)
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| Over the Counter, Herbal, Special health foods Vitamins, Supplements
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| Description of your problem/concern
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| History: (circle and explain) | |
| Penis: Normal/Abnormal Explain:________________________________________________________ | |
| Testicles: Normal/Abnormal Explain:______________________________________________________ | |
| Prostate: Normal/Abnormal Explain:______________________________________________________ | |
| Pubic and Underarm Hair: Normal/Abnormal Explain:_________________________________________ | |
| Beard: Normal/Abnormal Explain:_______________________________________________________ | |
| Circumcised: Yes/No | |
| Vasectomy: Yes/No Year___________ | |
| Nightime and Morning Erections: Yes/No | |
| Ejaculation: (Cum): Normal/Abnorma Explain:______________________________________________ | |
| Erection Problems: Yes/No Explain:______________________________________________________ | |
| Age of First ejaculation: __________ By: Masturbation/ Intercourse/ Other | |
| Do you masturbate: Yes/No How often:_____________________________________________ | |
| Age of first sexual encounter with another person: ____________ Male/Female | |
| Same sex experiences as adolescent or young adult: Yes/No | |
| History of Sexual Abuse: Yes/No (explain on separate sheet) | |
| Have you ever paid for sex: Yes/No | |
| Have you ever been paid to have sex with someone: Yes/No | |
| Have you ever been arrested,
dealt with the police or the law concerning any sexual matters: Yes/No Explain______________________________________________________________________________ |
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| Do you use erotic literature, erotic
videos, or sex toys to enhance sexual activity: Yes/No Explain______________________________________________________________________________ |
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| Do you have any religious or moral
concerns about any sexual activities: Yes/No Explain_________________________________________________________________________ |
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| Sexual Orientation - How do you see
yourself on the scale: Heterosexual 1 2 3 4 5 6 7 Homosexual |
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| Sexual partner: Yes/No-- Male/Female--
Living Together: Yes/No-- Time Together__________________ Married: Yes/No |
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| How often (on average) do you have intercourse: _____________________________________________ | |
| Previously married: Yes/No | |
| Number of children: ___________ Ages: Male: ______________ Female _________________________ | |
| Do children live with you? Yes/No | |
| Do you have a blended family with your partner (her children/your children) Yes/No | |
| Do you smoke to: Yes/No - Do You
use Alcohol Yes/No - Do you Use drugs Yes/No What Kind: ______________________ How Often: ________________________ |
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| Are you employed: Yes/No - Type of Work: _______________________________ | |
| Memories of sexual problems/concerns with initial sexual experiences:
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