Male Questionnaire - ER

Male Questionnaire

Pre-consultation Questionnaire for Dr. Elna Rudolph
Dear patient,

Thank you for taking the time to complete this questionniare. I will make the time spent with me during your consulation much more effective. I suggest that all biologically male patients complete this questionnaire before they see me.

The information you provide will remain fully confidential.

Please do not be offended by the nature of these questions. Since this is your first visit, we just want to make sure we have good background information. All patients answer exactly the same quesions, we do not imply anything by asking you these questions.

Where dates are requested, estimations are always appropriate.

Some fields are required and others not. If you do not complete a section that is not compulsory it will be assumed that you do not have a problem in this area or wish not to address it.

I am looking forward to meeting you soon and helping you to "love life with confidence"!

Kind regards

Dr. Elna Rudolph

Contact Information
Name*

NameSurname
Date of birth*

DayMonthYear
Age
Gender

MaleTrans FemaleGender non-conformingNon-binaryOther
What is your occupation?
Who referred you to me?
Who is your Urologist?
Who is your GP?
Please write down the name and contact details of any other specialist you see AND who you would like me to keep informed about your medical condition and treatment.

Hormones Replacement:
What form of Testosterone are you using?*

2.5% cream5% creamDepo Testosterone (1-3 weekly injection)PillsNebido (3monthly injection)Testosterone ImplantsOther
When was your last injection?

DayMonthYear

Rectal Examination
Have you had a rectal examination before (where a doctor used his finger to check your prostate by gently inserting it into your anus)*

YesNo
When was your last rectal exam?*

DayMonthYear

Please write down anything else you would like to bring under your Doctor's attention:
Should be Empty: