CoreLab Health - Men's Health Assessment

Do you have concerns about any of the following?

Getting and maintaining an erection

Delayed ejaculation

Both of the above

How's your sex life been lately?

It's okay, but I've noticed a few issues.

It could be better, to be honest. I'm hoping to find out what's going on.

It's been a bit of a struggle, and I'm ready to do something about it.

How often do your symptoms disrupt your sex life?

Most of the time

Every now and then

Hardly ever

When did your symptoms begin?

1 month ago

3 months ago

6 months ago

More than 1 year ago

What is your date of birth?

What is your height?

What is your current weight?

What sexual performance improvements are you looking for?

Make it easier to get an erection

Get harder erections

Make it easier to keep an erection

Improve control over when I ejaculate

Last longer during sex

How often do you have difficulty getting or staying as hard as you want before ejaculating?

Never

Every now and then

Sometimes

Usually or every time

Duration of persistence:

Under 1 minute

1 to 2 minutes

3 to 4 minutes

Which of the following medications have you previously taken to improve your control over ejaculation?

Prozac (Fluoxetine)

Aropax (Paroxetine)

Zoloft (Sertraline)

Cipramil (Citalopram)

Viagra (Sildenafil)

Cialis (Tadalafil) - As needed

Cialis Daily (Tadalafil Daily)

Levitra (Vardenafil)

Spedra (Avanafil)

Other

None

Which of the following medications have you used to improve your erections in the past?

Viagra (Sildenafil)

Cialis (Tadalafil) - As needed

Cialis Daily (Tadalafil Daily)

Levitra (Vardenafil)

Spedra (Avanafil)

Other medication

None of the above

Do you experience any of the following symptoms?

Low energy

Low motivation

Decreased physical endurance

Decreased physical strength

Daytime sleepiness

None of the above

In the past 6 months, have you ever felt severely dizzy, fainted, or nearly lost consciousness?

Yes

No

Have you ever been diagnosed with or prescribed medication for any of the following conditions?

Abnormal blood pressure, diabetes, or high cholesterol

Blood or immune system disorders (including HIV)

Gastrointestinal, stomach or liver disorders

Kidney problems

Circulation problems with arteries or veins

Eye conditions or diseases

Penis or prostate conditions (other than ED)

Brain, spinal cord or nerve problems (including stroke and seizures)

Other chronic medical conditions

None of these

Which of the following mental health or psychiatric conditions do you have?

Depression

Generalized anxiety disorder

Bipolar disease (manic depression)

Schizophrenia or other psychosis

Panic disorder

Other

None of the above

Do you have or have you ever been diagnosed with any of the following heart conditions?

Implanted defibrillator (ICD)

Pacemaker (PPM)

Heart failure

Heart attack (Myocardial Infarction)

Coronary artery disease (blocked arteries)

Heart surgery or procedure

Hypertrophic Obstructive Cardiomyopathy (HOCM)

Long QT Syndrome

Atrial fibrillation (AF)

Supraventricular tachycardia (SVT)

Other

None of the above

Which of the following medications or supplements do you take to improve your mental health?

TCAs (e.g., Endep/Amitriptyline, Tofranil/Imipramine)

SSRIs (e.g., Prozac/Fluoxetine, Zoloft/Sertraline, Lexapro/Escitalopram)

SNRIs (e.g., Efexor/Venlafaxine, Cymbalta/Duloxetine)

Avanza (Mirtazapine)

MAOIs (e.g., Nardil/Phenelzine, Parnate/Tranylcypromine)

Buspar (Buspirone)

Lithium

Zyban (Bupropion)

St. John's wort (supplement)

Other

No, I do not take any of these

Are you currently taking any of the following heart, blood pressure, urology or anticoagulant medications?

Nitrates (e.g., GTN spray or tablets, Imdur)

Prostate Medications (e.g., Tamsulosin, Silodosin)

Alpha-Blockers for blood pressure (e.g., Doxazosin)

Antiarrhythmics (e.g., Amiodarone, Sotalol, Flecainide)

Other Blood Pressure Meds (e.g., Nifedipine)

Warfarin (e.g., Coumadin, Marevan)

DOACs (e.g., Rivaroxaban/Xarelto, Apixaban/Eliquis)

Anti-platelet agents (e.g., Clopidogrel/Plavix, Aspirin)

Riociguat (Adempas)

Other

No, I am not taking any of these medications

Have you had any surgeries or medical procedures?

Yes

No

Do you currently or have you ever regularly smoked cigarettes?

Yes, I smoke cigarettes on some or most days

Yes, I previously smoked cigarettes but quit

No, I have never regularly smoked cigarettes

Have you taken any of the following recreational drugs in the past 6 months?

Poppers (amyl nitrite or related compounds)

Cocaine

Kratom

Methamphetamine (Ice / crystal meth)

MDMA (Ecstasy)

Other (please specify)

No, I have not used any recreational drugs in the past 6 months

Complete!

Thank you for completing the CoreLab Health Men's Health Assessment

Your responses have been recorded and will be reviewed by our medical team. You will receive personalized recommendations within 24 hours.