Questionnaire - Foundation Men's Health

Sexual Health Questionnaire

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Referral code (if you were referred)

If you were referred by a coach or partner, enter their referral code here.

Name(Required)

First Name Last Name

Email(Required)

Mobile phone number(Required)

Select your work type

Select your age range

Are you experiencing any of the following symptoms?

Symptoms

Difficulty achieving an erection

Difficulty maintaining an erection

Reduced sexual desire

Performance anxiety

Reduced confidence during sex

Symptoms vary or are inconsistent

All of the above

What health goal would you like help with?

Primary goal

Erectile dysfunction

Reduced libido

Sexual performance concerns

Combination of the above

Additional details

How long has this been going on?

Less than 3 months

3–12 months

12+ months

Do your symptoms occur:

All of the time

Some of the time

Occasionally

Do you wake with morning erections?

Yes

Sometimes

Have you previously used medication for sexual performance?

Yes

Do you have any of the following medical conditions?

Diabetes

High blood pressure

Heart disease

Anxiety or depression

None of the above

WHAT is your primary goal at this time?

Select the one that matters most.

Goal selection

Improved sexual performance

Improved confidence

Improved libido

All of the above

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Trt questionnaire

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Referral code (if you were referred)

If you were referred by a coach or partner, enter their referral code here.

Name(Required)

First Name Last Name

Email(Required)

Mobile phone number(Required)

Select your work type

Select your age range

Are you experiencing any of the following symptoms?

Symptoms

Low mood

Low libido

Fatigue

Decreased morning erections

Brain fog

All of the above

What health goal would you like help with?

Primary goal

Low testosterone support

Weight management

Mood support

Energy levels

Additional details

How long has this been going on?

Less than 3 months

3–12 months

12+ months

Have you had testosterone blood tests done in the last 12 months?

Upload your blood test results

Accepted file types: jpg, png, pdf, Max. file size: 10 MB.

Doctors to review results prior to consultation

Are you planning to have children in the next 12–24 months?

Yes

Not Sure

Some treatments used to manage low testosterone may affect sperm production and fertility. If you are planning to have children in the future, this does not mean treatment is unsuitable, but it may influence the type of treatment recommended. Our doctors will discuss appropriate options with you during your consultation.

Are you currently on testosterone replacement therapy (TRT)?

Yes

If yes have ability to upload recent blood test results.

Max. file size: 1 GB.

WHAT is your primary goal at this time?

Select the one that matters most.

Goal selection

More energy

Better libido

Improved mood & focus

All of the above

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Weight loss questionnaire

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Referral code (if you were referred)

If you were referred by a coach or partner, enter their referral code here.

Name(Required)

First Name Last Name

Email(Required)

Mobile phone number(Required)

Select your work type

Select your age range

What is your weight loss goal?

Height (cm)

Current weight

Weight loss goal

5–10 kg

10–20 kg

20 kg+

Not sure

Have you tried any of the following?

Multi-select

Dieting

Exercise

Medication

Just getting started

Health considerations

High blood pressure

High cholesterol

Type 2 diabetes

None of these

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Women's Health questionnaire

Step 1 of 5

20%

Let’s BEGIN with your details

Referral code (if you were referred)

If you were referred by a coach or partner, enter their referral code here.

Name(Required)

First Name Last Name

Email(Required)

Mobile phone number(Required)

Select your work type

Select your age range

Are you experiencing any of the following symptoms?

Symptoms

Low mood

Low libido

Fatigue

Hot flushes

Brain fog

Night sweats

Joint or muscle aches

Difficulty losing weight

All of the above

What health goal would you like help with?

Primary goal

Hormone optimisation

Weight management

Mood support

Energy levels

Perimenopause symptom management

Additional details

How long has this been going on?

Less than 3 months

3–12 months

12+ months

Have you had blood tests done in the last 12 months?

Upload your blood test results

Accepted file types: jpg, png, pdf, Max. file size: 10 MB.

Doctors to review results prior to consultation

Are you planning to have children in the next 12–24 months?

Yes

Not Sure

Are you currently on any medications?

Yes

Please list all medications, supplements and dosages (if known)

If yes have ability to upload recent blood test results.

Max. file size: 1 GB.

WHAT is your primary goal at this time?

Select the one that matters most.

Goal selection

More energy

Better libido

Improved mood & focus

All of the above

This field is hidden when viewing the form

Source

WHAT BRINGS YOU HERE TODAY?

Sexual Health Questionnaire

Trt questionnaire

Weight loss questionnaire

Women's Health questionnaire