SEXUAL CASE HISOTRY [short version]

Name :                                           Age:                                     Sex:                                

Education:

Spouse Age:                            Occupation           education;

Marital Status:

Date of Marriage/Divorce:

Reasons for Consultation:

Past Sexual Treatment details (also mention the medications taken)

History of any medical Problem (mention any medicines u r taking regularly)

Sexual Orientation: (Kinsey Scale)        0/1/2/3/4/5/6

Age of first Masturbaion.

Frequency of Masturbation :               

When started

Current Frequency

Frequency Before & After Dysfunction :

Night time erections;

Early morning erections

Age of first  intercourse     :                                                          

With whom (paid/   friend/    wife):

Frequency of Intercourse      :         

Before Dysfuction:

After Dysfuction :

Details of Foreplay                                   

No of  Sexual partners:    

Current

Pre Marital:

Extra Marital       :                            

Status of Oral Sex;

Spouse participation in sex;

Expectations in Marriage :

Expectation from Doctor.

Inter Personal Relation & Conflicts

Likes & Dislikes in Spouse             

Send all the information provided in the contact address.

After getting the basic sexual profile of yours, the area of the problem is detected .Then a problem specific questionnaire will be administered to you to get the in depth details of your sexual dysfunction.Thus a diagnosis will be made and the treatment plan will be designed based on that information.