Male Genital Exam Questionnaire Form
Please complete all questions below to help us understand your health concerns and history before your appointment.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
What is your primary reason for today's exam?
*
Which symptoms are you currently experiencing?
*
Pain or discomfort
Swelling or lumps
Redness or rash
Discharge
Itching
Other
How long have you been experiencing these symptoms?
*
Please Select
Less than 1 week
1–4 weeks
1–3 months
More than 3 months
Do you have any relevant medical conditions?
Diabetes
Hypertension
Urinary tract infections
Sexually transmitted infections
None
Other
Are you currently taking any medications?
Yes
No
Have you had any previous genital exams or procedures?
Yes
No
Please provide any additional information or concerns.
Submit
Should be Empty: