Health Assessment | Optimale Health

What are you looking to treat?

(Please select one)

Getting or maintaining an erection (ED) Lasting long enough during sex or climax too quick (PE) Both (ED and PE)

Do you ever have a problem getting or maintaining an erection that's hard enough for penetration?

(Please select one)

Yes, everytime Yes more than half of the time Yes, on occasion I never have a problem

How long have you been experiencing erectile dysfunction?

(Please select one)

Less than 6 months 6 to 12 months More than 12 months

How difficult is it for you to delay ejaculation?

(Please select one)

Not difficult Somewhat difficult Very Difficult Extremely difficult

How often do you ejaculate before you want to?

(Please select one)

Less than half the time More than half the time Every time

How long has premature ejaculation been an issue for?

(Please select one)

From the moment I started having sex When I started a new relationship With my long term partner

Which of the following best describes your desire to have sex?

(Please select one)

Less than it was Less than it was because I know I have trouble with my erection or ejaculating Unchanged

Are you anxious to have sex due to this issue?

(Please select one)

No Yes

Have you ever taken or used any medications or supplements for PE and/or ED?

(Please select one)

No Yes

Did you ever experience the following side effects while taking this medication?

(Select any that apply)

Dizziness, nausea or tiredness Congested sinus or headaches Muscle pain, chest pain or heart palpatations No

Do you currently or have you suffered from any of these conditions?

(Select any that apply)

Abnormality to the penis (Peyronie’s Disease), Painful erections, Painful ejaculations, Tight foreskin Heart disease, Heart attack, Arrhythmia, Abnormal heart beat, Aortic stenosis, Chest pain (Angina), Uncontrolled high blood pressure (more than 160/90) Kidney, Liver or Lung problems. Cancer, Bleeding conditions or Diabetes. Nerve, Neurological problems or Loss of vision. Using hormones or steroids None

Do you frequently get dizzy if you stand up suddenly? e.g Bending down and standing up quickly, or getting out of bed in a hurry?

(Please select one)

No Yes

Do you currently suffer from any mental disorders you are currently taking treatment for? This is a required question for Australian doctors.

(Select any that apply)

Anxiety or Depression Bipolar disorder Psychotic disorder Other None

Do you have any allergies to medication or anything else?

(Please select one)

No Yes

Please list all your known allergies

Are you currently taking any medications, supplements or herbs?

(Please select one)

No Yes

Please list all medications and supplements you are currently taking

Do you use any of the following recreational drugs? Only your doctor will see this information.
"IMPORTANT PLEASE READ (your life depends on it) - A number of the medications that are prescribed through Optimale Health can interact dangerously with recreational drugs. If you are prescribed a medication please follow the instructions from your treating doctor about drug use."

(Please select one)

Cannabis, Cocaine, Ecstacy or MDMA Other No

Have you ever had any major surgery within the last 12 month?

(Please select one)

No Yes

Please list all surgeries you undertook in the past 12 months

Do you ever experience any of the following symptoms when passing urine?

(Select any that apply)

Problem with starting or stopping your stream Going more than you used to, especially at night Interrupted stream, stopping, starting, dribbling None

What is your date of birth?

How tall are you? In centimetres.

How much do you weigh?

How often do you exercise?

(Please select one)

3-5 times a week 2-3 times per week Once a week Not a priority

How would you describe your diet?

(Please select one)

Very healthy Moderately healthy Needs a lot of work It's not a priority

How many hours of sleep do you get a night uninterrupted?

(Please select one)

8 hours or more 6 to 8 hours Less than 6 hours

How much alcohol do you consume per week?

(Please select one)

None 1 to 4 standard drinks 5 to 10 standard drinks 10+ standard drinks

Do you smoke, vape or use tobacco?

(Please select one)

Everyday Socially No

Please add any additional information that you want our doctors to know?

Full Name

Email

Please give us your mobile number, should you choose to be contacted via call or SMS

Do you confirm that the information you have given is true and accurate, that any prescribed medication is solely for yourself, and that if prescribed a medication, you will review the information supplied regarding the medication and side effects?

(Please select one)

Yes

How difficult is it for you to delay ejaculation?

(Please select one)

Not difficult Somewhat difficult Very Difficult Extremely Difficult

How often do you ejaculate before you want to?

(Please select one)

Less than half the time More than half the time Every time

How long has premature ejaculation been an issue for?

(Please select one)

From the moment I started having sex When I started a new relationship With my long term partner

Which of the following best describes your desire to have sex?

(Please select one)

Less than it was Less than it was because I know I have trouble with erection or ejaculating Unchanged

Are you anxious to have sex due to this issue?

(Please select one)

No Yes

Have you ever taken or used any medications or supplements for premature ejaculation?

(Please select one)

No Yes

Did you ever experience the following side effects while taking this medication?

(Select any that apply)

Dizziness or Nausea or Tiredness Congested sinus or Headache Muscle Pain or Chest Pain or Heart Palpatations No

Do you currently or have you suffered from any of these conditions?

(Select any that apply)

Abnormality to the penis (Peyronie’s Disease), Painful erections, Painful ejaculations, Tight foreskin. Heart disease, Heart attack, Arrhythmia, Abnormal heart beat, Aortic stenosis, Chest pain (Angina), Uncontrolled high blood pressure (more than 160/90). Kidney, Liver or Lung problems. Cancer, Bleeding conditions or Diabetes. Nerve, Neurological problems or Loss of vision. Using hormones or steroids None

Do you frequently get dizzy if you stand up suddenly? e.g Bending down and standing up quickly, or getting out of bed in a hurry?

(Please select one)

No Yes

Do you currently suffer from any mental disorders you are currently taking treatment for? This is a required question for Australian doctors.

(Select any that apply)

Anxiety or Depression Bipolar Disorder Psychotic Disorder Other None

Do you have any allergies to medication or anything else?

(Please select one)

No Yes

Please list all your known allergies

Are you currently taking any medications, supplements or herbs?

(Please select one)

No Yes

Please list all medications and supplements you are currently taking
IMPORTANT PLEASE READ (your life depends on it) - ED tablets and nitrate medications such as GTN spray, GTN tablets or GTN patches can cause a fatal reaction. Glyceryl Trinitrate and other drugs that alter your heart rate can have fatal consequences. You must not take ED medication if you take a GTN spray (such as Nitrolingual), tablets (such as Nicorandil or Nitrostat), patches (such as Transiderm or Minitran), GTN gels or creams. See your regular GP to discuss alternative options if you are unsure. Please confirm that you understand and have disclosed all medications you are taking.

Do you use any of the following recreational drugs? Only your doctor will see this information.
"IMPORTANT PLEASE READ (your life depends on it) - A number of the medications that are prescribed through Optimale Health can interact dangerously with recreational drugs. If you are prescribed a medication please follow the instructions from your treating doctor about drug use."

(Please select one)

Cannabis, Cocaine, Ecstacy or MDMA Other No

Have you ever had any major surgery within the past 12 months?

(Please select one)

No Yes

Please list all surgeries you undertook in the past 12 months

Do you ever experience any of the following symptoms when passing urine?

(Select any that apply)

Problem with starting or stopping your stream Going more than you used to, especially at night Interrupted stream; stopping, starting, dribbling None

What is your date of birth?

How tall are you? In centimetres.

How much do you weigh?

How often do you exercise?

(Please select one)

3-5 times a week 2-3 times a week Once a week Not a priority

How would you describe your diet?

(Please select one)

Very healthy Moderately healthy Needs a lot of work It's not a priority

How many hours of sleep do you get a night uninterrupted?

(Please select one)

8 hours or more 6 to 8 hours Less than 6 hours

How much alcohol do you consume per week?

(Please select one)

None 1 to 4 standard drinks 5 to 10 standard drinks 10+ standard drinks

Do you smoke, vape or use tobacco?

(Please select one)

Everyday Socially No

Please add any additional information that you want our doctors to know?

Full Name

Email

Please give us your mobile number, should you choose to be contacted via call or SMS

Do you confirm that the information you have given is true and accurate, that any prescribed medication is solely for yourself, and that if prescribed a medication, you will review the information supplied regarding the medication and side effects?

(Please select one)

Yes

Do you ever have a problem getting or maintaining an erection that's hard enough for penetration?

(Please select one)

Yes, everytime Yes, more than half of the time Yes, on occasion I never have a problem

Which of the following best describes your desire to have sex?

(Please select one)

Less than it was Less than it was because I know I have trouble with erection or ejaculating Unchanged

How long have you been experiencing Erectile Dysfunction?

(Please select one)

Less than 6 months 6 to 12 months More than 12 months

Are you anxious to have sex due to this issue?

(Please select one)

No Yes

Have you ever taken or used any medications or supplements for erectile dysfunction before?

(Please select one)

No Yes

Did you ever experience the following side effects while taking this medication?

(Select any that apply)

Dizziness, nausea or tiredness Congested sinus or headache Muscle pain, chest pain or heart palpatations No

Do you currently or have you suffered from any of these conditions?

(Select any that apply)

Do you frequently get dizzy if you stand up suddenly? e.g Bending down and standing up quickly, or getting out of bed in a hurry?

(Please select one)

No Yes

Do you currently suffer from any mental disorders you are currently taking treatment for? This is a required question for Australian doctors.

(Select any that apply)

Anxiety or Depression Bipolar Disorder Psychotic Disorder Other None

Do you have any allergies to medication or anything else?

(Please select one)

No Yes

Please list all your known allergies

Are you currently taking any medications, supplements or herbs?

(Please select one)

No Yes

Please list all medications and supplements you are currently taking
IMPORTANT PLEASE READ (your life depends on it) - ED tablets and nitrate medications such as GTN spray, GTN tablets or GTN patches can cause a fatal reaction. Glyceryl Trinitrate and other drugs that alter your heart rate can have fatal consequences. You must not take ED medication if you take a GTN spray (such as Nitrolingual), tablets (such as Nicorandil or Nitrostat), patches (such as Transiderm or Minitran), GTN gels or creams. See your regular GP to discuss alternative options if you are unsure. Please confirm that you understand and have disclosed all medications you are taking.

Do you use any of the following recreational drugs? Only your doctor will see this information.
IMPORTANT PLEASE READ (your life depends on it) - A number of the medications that are prescribed through Optimale Health can interact dangerously with recreational drugs. If you are prescribed a medication please follow the instructions from your treating doctor about drug use.

(Please select one)

Cannabis, Cocaine, Ecstacy or MDMA Other No

Have you ever had any major surgery within the past 12 months?

(Please select one)

No Yes

Please list all surgeries you undertook in the past 12 months

Do you ever experience any of the following symptoms when passing urine?

(Select any that apply)

Problem with starting or stopping your stream Going more than you used to, especially at night Interrupted stream; stopping, starting, dribbling None

What is your date of birth?

How tall are you? In centimetres.

How much do you weigh?

How often do you exercise?

(Please select one)

3-5 times a week 2-3 times a week Once a week Not a priority

How would you describe your diet?

(Please select one)

Very healthy Moderately healthy Needs a lot of work It's not a priority

How many hours of sleep do you get a night uninterrupted?

(Please select one)

8 hours or more 6 to 8 hours Less than 6 hours

How much alcohol do you consume per week?

(Please select one)

None 1 to 4 standard drinks 5 to 10 standard drinks 10+ standard drinks

Do you smoke, vape or use tobacco?

(Please select one)

Everyday Socially No

Please add any additional information that you want our doctors to know?

Full Name

Email

Please give us your mobile number, should you choose to be contacted via call or SMS

Do you confirm that the information you have given is true and accurate, that any prescribed medication is solely for yourself, and that if prescribed a medication, you will review the information supplied regarding the medication and side effects?

(Please select one)

Yes

Your results

SYMPTOMS:

Take control of your sexual health.

Optimale Health specialises in safe and healthy weight loss programs, testosterone optimisation programs and sexual dysfunction therapies.

YOUR PROGRESS