Male Patients Form 2

EMLA PRILIGY If other, please specify:

I NOTICED IT WHEN I STARTED HAVING SEX THIS IS ONLY A RECENT DEVELOPMENT If other, please specify:

EVERYTIME I HAVE SEXUAL INTERCOURSE ONLY WHEN I HAVE SEXUAL INTERCOURSE WITH A NEW PARTNER If other, please specify:

NO If YES, I DO, please specify:

YES If YES, I HAVE, please specify:

NO If YES, I DO, please specify:

NO If YES, I HAVE, please specify advice given:

NO If YES, I HAVE, please specify:

NO If YES, I WAS, please specify:

NO If YES, I DO, please specify:

NO If YES, I DO, please specify:

NO If YES, I DO, please specify:

NO If YES, I DO, please specify:

NO If YES, I DO, please specify:

MALE FEMALE

I CONFIRM