Medical History and Examination
Part I to be completed by applicant
Date of birth:
What is your family situation (Married, in relationship, single...)?
Do you live alone?
Do you smoke tobacco?
Do you drink alcohol? How much?
Do you use recreational drugs?
Do you exercise regularly?
Are you happy with your weight?
List all the surgeries you ever had.
List all prescribed medications you have taken over the last 12 months.
Did any laboratory test (blood, urine, imaging, etc...) ever show abnormal results?
Did you ever have an accident resulting in permanent posture or gait alteration?
How many partners did you have over the last 12 months:
______ Men, ________ Women
Are you circumcised?
If not, do you have any difficulty retracting your foreskin?
What is you experience with oral sex?
What is your experience with anal sex?
List all accessories (“sex toys”) you are using.
Do you have any pain during sexual activities?
Do you have any problem getting an erection?
Are you satisfied with the length and girth of your penis?
Are you satisfied with the firmness of your penis.
How often do you have premature ejaculation?
Do you ejaculate every time you masturbate?
Are you satisfied with the time it takes?
Are you satisfied with the volume of your ejaculations?
Part II to be completed by PlayMD.
Name of the examiner
Date of examination
Oral & throat
Vascular state of genitals under stimuli.
Cardiac reaction to stimuli
Hyper-sensitivity of sacrum peripheral nerves
Response time to stimulations