Male Patients Form

NO If YES, I HAVE ALLERGIES, please specify:

YES NO

YES NO

NO If YES, I HAVE, please specify:

LESS THAN 12 MONTHS AGO MORE THAN 12 MONTHS AGO

STAYS THE SAME GETTING WORSE OVER TIME If other, please specify:

SUDDENLY GRADUALLY

MORE THAN 12 MONTHS AGO LESS THAN 12 MONTHS AGO

SOFT STIFF If other, please specify:

YES, I WAS ABLE TO PENETRATE NO, I COULD NOT PENETRATE If other, please specify:

YES, I WAS ABLE TO CLIMAX NO, I WAS NOT ABLE TO CLIMAX If other, please specify:

YES NO

YES NO

HARD SOFT

NO If YES, please specify:

YES NO Not currently in a relationship

NO If YES, I DO, please specify:

NO If YES, I AM, please specify:

NO If YES, I AM, please specify:

NO If YES, I AM, please specify:

MALE FEMALE

I CONFIRM