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(289) 632-8825

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TREATMENTS
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Thank you for your payment

Please answer the questions below.
Your answers will be sent to our clinic for TRT eligibility assessment.

Testosterone Replacement Therapy Assessment

"*" indicates required fields

YOUR SYMPTOMS

Do you have a lack of energy?

Yes

No

Do you have a decrease in libido (sex drive)?

Yes

No

Do you have a decrease in strength and/or endurance?

Yes

No

Have you lost height?

Yes

No

Have you noticed a decreased "enjoyment of life"?

Yes

No

Are you sad and/or grumpy?

Yes

No

Are your erections less strong?

Yes

No

Have you noticed a recent deterioration in your ability to play sports?

Yes

No

Are you falling asleep after dinner?

Yes

No

Has there been a recent deterioration in your work performance?

Yes

No

YOUR MEDICAL HISTORY

Current Weight (lbs)

Height (inches)

What is your most recent blood pressure reading?

Do you have any health issues?

Yes

No

If yes, please specify

Please list past surgeries (if applicable)

Do you take any medications?

Yes

No

If yes, please specify

Do you have any allergies to medication?

Yes

No

If yes, please specify

How many alcoholic drinks do you consume per week?

None

1-4

5 or more

Do you smoke cigarettes?

Yes

No

Do you have a desire to maintain fertility (plans to have children in the future)?

Yes

No

Are you a patient at Precision Men’s Sexual Health Clinic?

Yes

No

YOUR PERSONAL DETAILS

Name*

First name * Last name *

Date of birth

YYYY dash MM dash DD

Address

Street Address City Province Postal Code

Phone*

Email*

Provide additional information, if necessary

Consent

I agree that the above medical information is factual to the best of my knowledge.

I understand that in the event of worsening of symptoms or allergic reaction to medication, I will seek immediate medical care.

Because sexual wellness is an integral part of your health and happiness.

Contact us for more information

Mississauga Erectile Dysfunction Clinic for Men

Book a Consultation

10 Kingsbridge Garden Circle
Suite 305
Mississauga, ON L5R 3K6

77 Hunter Street East
Hamilton, ON L8N 1M4

51 Benton Street
Kitchener, ON N2G 3H1

180 Vine St S Unit 201
St. Catharines, ON L2R 7P3

672 Brant Street, Suite 200
Burlington, ON L7R 2H3

195 Henry St, Unit 05
Brantford, ON N3S 5C9

Tel: (289) 632-8825

Fax: (905) 502-1426

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CONCERNS

ERECTILE DYSFUNCTION
PEYRONIE'S DISEASE
LOW TESTOSTERONE
PREMATURE EJACULATION
PENIS ENLARGEMENT
DELAYED EJACULATION
FRENULUM BREVE
PENILE LICHEN SCLEROSUS

TREATMENTS

SHOCKWAVE THERAPY
INJECTION THERAPY
TRIMIX
PENILE NEUROMODULATORS
SEX THERAPY
PENILE FRENULECTOMY
PENILE FILLERS
LOW T QUIZ
ED QUIZ

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