Male

Name:

Date of Birth:

Address:

City/Town:                                                      State:                                       Postcode:

Tel no:                                                                                   Mobile:

Email Address:

Occupation:                                                                   Height:                                          Weight:

Your Doctor’s Name:

Address;

Do you Smoke:                                      How often and How much:

Did you ever smoke:                                 When did you give up:

Do you drink Alcohol:                            How often and How much:

Do you have any allergies:

Marital Status:                                    What Work do you do:

What operations have you had:

Major illnesses or Diseases:

What medicines are you on:

Family history: Any important illness/diseases in the family:

========================================================

=======================================================

Hormone Checklist:

Symptom                                 None      Mild     Moderate    Severe

Loss of Motivation (Drive)

Loss of Sex Drive

Irritable

Anxiety level

Depression

Problems handling stress

Fatigue

Needs Daytime sleep

Frequency of spontaneous erections

Reduced frequency intercourse

Loss of muscle tone

Increased belly/Breast size

Loss of competitiveness

Loss of interest in exercise/sport

Loss of body hair

Skin becoming fine/frail

Loss of height

Falling asleep in front of Telly

Prostate problem.

Print this out and bring it with you when seeing Dr Holloway

Do the next 2 as well, print and bring in with you.

========================================================

 The Sexual Health Inventory for Men

Each question has several possible responses. Circle the number of the response that best describes your own situation. Please be sure that you select one and only one response for each question.
OVER THE PAST 6 MONTHS:
1. How do you rate your confidence that you could get and keep an erection?
Very Low Low Moderate High Very High
1 2 3 4 5
2. When you had erections with sexual stimulation, how often were your erections hard enough for penetration (entering your partner)?
No sexual activity Almost never or never A few times (much less than half the time) Sometimes (about half the time) Most times (much more than half the time) Almost always or always
0 1 2 3 4 5
3. During sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) you partner?
Did not attempt intercourse Almost never or never A few times (much less than half the time) Sometimes (about half the time) Most times (much more than half the time) Almost always or always
0 1 2 3 4 5
4. During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?
Did not attempt intercourse Extremely difficult Very difficult Difficult Slightly difficult Not difficult
0 1 2 3 4 5
5. When you attempted sexual intercourse, how often was it satisfactory for you?
Did not attempt intercourse Almost never or never A few times (much less than half the time) Sometimes (about half the time) Most times (much more than half the time) Almost always or always
0 1 2 3 4 5

SCORE: Add the numbers corresponding to questions 1−5. If your score is 21 or less, you may want to speak with your doctor.

International prostate symptom score (IPSS)

Name:                                                                                                    Date:

Not at all

Less than 1 time in 5

Less than half the time

About half the time

More than half the time

Almost always

Your score

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

0

1

2

3

4

5

Frequency

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

0

1

2

3

4

5

Intermittency

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

0

1

2

3

4

5

Urgency

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

0

1

2

3

4

5

Weak stream

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

0

1

2

3

4

5

Straining

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

0

1

2

3

4

5

None

1 time

2 times

3 times

4 times

5 times or more

Your score

Nocturia
Over the past month, 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?

0

1

2

3

4

5

Total IPSS score

 

Quality of life due to urinary symptoms

 

 

 

Delighted

Pleased

Mostly satisfied

Mixed – about equally satisfied and dissatisfied

Mostly dissatisfied

Unhappy

Terrible

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?

0

1

2

3

4

5

6

Total score: 0-7 Mildly symptomatic; 8-19 moderately symptomatic; 20-35 severely symptomatic.

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