PATIENT MEDICAL HISTORY AND PRE-EXAMINATION INFORMATION FORM
Your information will be kept in strict confidence. Please copy and complete, and then email back. All Patients are requested to complete this form prior to scheduling their examination.
PATIENT EMAIL ADDRESS:
PATIENT CITY and STATE:
Height: ( )feet ( )inches
Weight: ( )Lbs
Build: ( )slim ( )average ( )a few extra pounds ( )bbw
Measurements: ( )breast ( )waist ( )hips
Brassiere Cup Size: ( ) Delete
Natural Hair Color:
Pubic Hair: ( )dense ( )trimmed ( )shaved () naturally sparse
Single ( ) Married ( ) Divorced/Separated ( ) Widow/Widower ( ) Other (
Are you currently in a Relationship? ( )
If Yes: Normal M/F ( ) Gay ( ) Poly ( )
Straight ( ) Bi-sexual ( ) Gay ( ) Trans-sexual ( )
Your examination will be exceedingly thorough and complete. In addition to the typical procedures, there are specialized procedures to ascertain the sexual health, function, and responsiveness of the patient. Any information you provide will be kept in strictest confidence.
Do you authorize the basic exam? Yes ( ) No ( )
Do you authorize the additional procedures? Yes ( ) No ( )
You may be examined while wearing an exam gown, or optionally nude. Please state your preference: Gown ( ) Nude ( )
Feel free to add additional information, if space is insufficient, in the space provided for thoughts and feelings at the end of the questionnaire.
Any physical limitations?
Any current medical condition(s) the Doctor should be aware of?
Allergies: (ie latex, vinyl, lubricants, iodine, betadine, shellfish, medications, etc.)
What medications do you regularly take and what are they for?
Do you have any dietary restrictions?
Do you exercise regularly?
Do you smoke? ( ) If Yes, how much and how often?
Do you use alcohol? ( ) If Yes, how much and how often?
Do you use recreational drugs? ( ) If Yes, how much and how often? What kinds?
Have you been a victim of sexual abuse? ( )
Check any symptoms you currently are experiencing:
Change in appetite: ( )
Fatigue: ( )
Excessive hair loss/growth: ( )
Change in sleep habits: ( )
Urinary incontinence; ( )
Bowel problems: ( )
Loss of sexual desire: ( )
Urethral itching or sensitivity: ( )
Difficulty swallowing: ( )
Constipation: ( )
Groin itching: ( )
Pain () Describe:
URINARY AND BOWEL
Overly frequent Urination? ( )
Slow urine flow ()
Pain during Urination? ( )
Urgency of Urination? ( )often ( )moderate ( )rarely
History of Urinary Tract Infection? ( )often ( )moderate ( )rarely
Do you have daily Bowel Movements? ( )
If No, how often? every other day ( ) every 3 days ( ) other ( )
If Yes, number of Bowel Movements per day? ( )1 ( )2 ( )3 ( )more than 3
Constipation? ( )often ( )moderate ( )rarely
Diarrhea? ( )often ( )moderate ( )rarely
Do you use Laxatives? ( )
Do you mainly use laxatives when you haven’t had Bowel Movements for ( )2 ( )3 ( ) more than 3 days
When was the last time you were constipated ( ) one week ( ) more than two weeks ( ) more than one month
Do you feel that the laxative immediately help you ( )
Do yo use them more that one day when constipated ( )
Do you sometimes use laxatives as pretreatment before enemas ( )
Frequency of use? ( )often ( )moderate ( )rarely
Type of laxatives? (if used) ( )suppositories ( )oral Names:
Do you take Enemas? ( )often ( )moderate ( )rarely
Your Enema habits:
Do you take less than one qt ( ) 2 qt and more ( ) 3 qt ( ) More than 3 quarts ()
Do you use Enema bag ( ) Enema can ( ) Bulb ( ) Packaged enema () (Kind: _____) Other:______
Which kind of nozzle – note the dimesions and the brand:……………………..
What enema solutions do you use/have tried:
Soapy water ( ) Water with salt ( ) Baking soda ( ) Coffee ( ) Oliveoil/mineraloil ( ) Other: _______
HISTORY AND DETAILS
Manual Rectal Exam/ DRE? ( )
Rectal Speculum/Proctoscope Exam? ( )
Did you experience sexual arousal? ( )
Did you masturbate following Exam? ( )
Do you do breast self-exam regularly (Yes, men should do this!)? ( )
Do you do testicular self exams monthly?
Do you do prostate self exams?
Do you produce precum spontaneously? ( )
Do your penis erect spontaneously? ( )
Do you have problems with erectile dysfunction or impotence?
Do you have problems with ejaculatory dysfunction (premature or delayed ejaculation, pain during or following ejaculation) ()
BASIC SEXUAL HISTORY
Age of first masturbation: ( )
Age of first orgasm: ( )
Age of first receiving oral: ( )
Age of first performing oral: ( )
Age of first vaginal intercourse: ( )
Was your first vaginal intercourse painful? ( )
Age of first anal intercourse as giver: ( )
Age of first anal intercourse as receiver: ()
Was your first anal intercourse painful? ( )
Are you sexually active? ( )
If Yes, how often? ( )daily ( )2-6 days/week ( )weekly ( )rarely
Do you have any bi-sexual tendencies? ( )
If yes to the above how old was you at first time ? ( )
Do you frequently do bisexual activities ? ( ) When was the last time ? ( )
Have you ever been buttfucked ? ( )
Have you ever buttfucked a male ? ( )
Have you ever licked/sucked a cock ( )
If Yes, have you had a male partner? ( )
Do you often experience multiple orgasms? ( )
Have you ever experienced an anal orgasm? ( ) Prostate milking ( )
Do you masturbate? ( )
If Yes, how often? ( )daily ( )2-6 days/week ( )weekly ( )rarely
Have you ever used a vibrator? ( )rectally ( )On penis () other: ____________ ( )No
Have you ever used a dildo? ( )On penis ( )rectally () Other: _______________ ( )No
Have you ever used a shower massage? ( )On penis ( )rectally () Other: _______________ ( )No
Have you ever used a vibrating egg? ( )rectally () Other: _______________ ( )No
Have you inserted fruits/veggies? ( )rectally ( )No
Have you inserted other objects for sexual pleasure? ( )rectally () Other: __________ ( )No
If yes, list all other objects used:
Have you ever used enemas or suppositories for sexual arousal? ()
Do you ejaculate a big amount ? ( )
Do you ejaculate with a high viscosity ? ( )
Have you observed if volume or viscosity is a function of the time in between your
ejaculations ? ( ) If so, how does it change ? ______
How many sexual partners do you have monthly?
When was the last time you had intercourse?
Was it protected sex?
What sexual activities did you do?
Do you practice “safe sex” every time?
How often do you engage in sexual activities (other than masturbating) monthly?
Have you ever had a prostate milking ? ( )
Do you currently use birth control ( )
Type of birth control:
Prevention of Sexually Transmitted Infections:
When you were last tested for sexually transmitted infections?
Did you test positive for any sexually transmitted infections?
If you have tested positive for any STI’s, what measures do you take to prevent transmitting them?
Have you had unprotected sex since you were last tested for STI’s?
If Yes, what was the status of STI testing of your partner(s)?
YOUR EXAMINATION - Additional Procedures
In addition to the normal medical examination procedures (height, weight, pulse, blood pressure, breast exam, pelvic exam, etc) certain other procedures may be performed. Please indicate your acceptance of the following procedures:
Rectal Exam (digital, speculum, rectal scoping): ( )
If Yes, Enemas will be administered before the Rectal exam.
Basal Temperature recording - Rectal: ( ) Urethral: ( )
Will you provide a supervised Urine specimen? ( )
If necessary, will you provide a Stool specimen? ( )
If necessary, will you provide a supervised Stool specimen? ()
Do you agree to have your bi-sexual tendencies tested ? ( )
If necessary, will you provide a rectal body temperature journal and a journal about other issues over a period of time before the examination ( )
Anus ( )
Penis ( )
Other as prescribed ()
Anus ( )
Nipples ( )
Scrotum ( )
You Physician will perform procedures to ascertain your sexual health, function, and responsiveness. This may include the stimulation of your, anus, penis and prostate.
Do you agree to the Sexual Arousal and Responsiveness procedures? ( )
Do you agree to orgasm after being sexually stimulated? ( )
Do you agree to let the Doctor measure the strength of your orgasm? This may require a rectal probe ( )
Do you agree to let the Doctor measure the volume of your ejaculation? ( )
BDSM activities: Do agree to answer a questionnaire about your desires and experiences ? ( )
Do you agree to include BDSM activities in the examination if the doctor decide it ? ( )
Do you agree to have a male doctor to a 360 degree through test of your bi-sexuality ( ) ?
Do you agree that the doctor may write a formal journal/report for each examination ? ( )