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NP Bio ‘O’ Questionnaire
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Please be advised that only the person that the form is referring to can fill out this form.
Full name
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Email
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DOB
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Delivery address
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Mobile number
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The Doctor will create a prescription for the most suitable products for you but please still let us know which products are you mainly interested in and how many
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Photo of ID/Passport
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Please note that a copy of a valid photo ID is required in order to confirm your identity, your details are deleted after they have been verified
FSFI SCORING APPENDIX
With almost 20 years’ experience in researching and treating patients with hormonal imbalances, Dr Eccles has found that one of the most common symptoms (and yet, the least discussed), to be the decline of libido and sexual enjoyment in both men and women. This can affect mood; self-esteem; put unnecessary strain on relationships, and is not a symptom to be ignored. We understand that this can be an extremely sensitive and personal issue however, so would invite you to complete the following pages of this short questionnaire ahead of your consultation if you feel that your libido or enjoyment during sex could benefit from improvement.
1. Over the past 4 weeks, how often did you feel sexual desire or interest?
5 = Almost always or always
4 = Most times (more than half the time)
3 = Sometimes (about half the time)
2 = A few times (less than half the time)
1 = Almost never or never
2. Over the past 4 weeks, how would you rate your level (degree) of sexual desire or interest?
5 = Very high
4 = High
3 = Moderate
2 = Low
1 = Very low or none at all
3. Over the past 4 weeks, how often did you feel sexually aroused ("turned on") during sexual activity or intercourse?
5 = Almost always or always
4 = Most times (more than half the time)
3 = Sometimes (about half the time)
2 = A few times (less than half the time)
1 = Almost never or never
0 = No sexual activity
4. Over the past 4 weeks, how would you rate your level of sexual arousal ("turn on") during sexual activity or intercourse?
5 = Very high
4 = High
3 = Moderate
2 = Low
1 = Very low or none at all
0 = No sexual activity
5. Over the past 4 weeks, how confident were you about becoming sexually aroused during sexual activity or intercourse?
5 = Very high confidence
4 = High confidence
3 = Moderate confidence
2 = Low confidence
1 = Very low or no confidence
0 = No sexual activity
6. Over the past 4 weeks, how often have you been satisfied with your arousal (excitement) during sexual activity or intercourse?
5 = Almost always or always
4 = Most times (more than half the time)
3 = Sometimes (about half the time)
2 = A few times (less than half the time)
1 = Almost never or never
0 = No sexual activity
7. Over the past 4 weeks, how often did you become lubricated ("wet") during sexual activity or intercourse?
5 = Almost always or always
4 = Most times (more than half the time)
3 = Sometimes (about half the time)
2 = A few times (less than half the time)
1 = Almost never or never
0 = No sexual activity
8. Over the past 4 weeks, how difficult was it to become lubricated ("wet") during sexual activity or intercourse?
0 = No sexual activity
1 = Extremely difficult or impossible
2 = Very difficult
3 = Difficult
4 = Slightly difficult
5 = Not difficult
9. Over the past 4 weeks, how often did you maintain your lubrication ("wetness") until completion of sexual activity or intercourse?
5 = Almost always or always
4 = Most times (more than half the time)
3 = Sometimes (about half the time)
2 = A few times (less than half the time)
1 = Almost never or never
0 = No sexual activity
10. Over the past 4 weeks, how difficult was it to maintain your lubrication ("wetness") until completion of sexual activity or intercourse?
0 = No sexual activity
1 = Extremely difficult or impossible
2 = Very difficult
3 = Difficult
4 = Slightly difficult
5 = Not difficult
11. Over the past 4 weeks, when you had sexual stimulation or intercourse, how often did you reach orgasm (climax)?
5 = Almost always or always
4 = Most times (more than half the time)
3 = Sometimes (about half the time)
2 = A few times (less than half the time)
1 = Almost never or never
0 = No sexual activity
12. Over the past 4 weeks, when you had sexual stimulation or intercourse, how difficult was it for you to reach orgasm (climax)?
0 = No sexual activity
1 = Extremely difficult or impossible
2 = Very difficult
3 = Difficult
4 = Slightly difficult
5 = Not difficult
13. Over the past 4 weeks, how satisfied were you with your ability to reach orgasm (climax) during) sexual activity or intercourse?
5 = Very satisfied
4 = Moderately satisfied
3 = About equally satisfied and dissatisfied
2 = Moderately dissatisfied
1 = Very dissatisfied
0 = No sexual activity
14. Over the past 4 weeks, how satisfied have you been with the amount of emotional closeness during sexual activity between you and your partner?
5 = Very satisfied
4 = Moderately satisfied
3 = About equally satisfied and dissatisfied
2 = Moderately dissatisfied
1 = Very dissatisfied
0 = No sexual
15. Over the past 4 weeks, how satisfied have you been with your sexual relationship with your partner?
5 = Very satisfied
4 = Moderately satisfied
3 = About equally satisfied and dissatisfied
2 = Moderately dissatisfied
1 = Very dissatisfied
16. Over the past 4 weeks, how satisfied have you been with your overall sexual life?
5 = Very satisfied
4 = Moderately satisfied
3 = About equally satisfied and dissatisfied
2 = Moderately dissatisfied
1 = Very dissatisfied
17. Over the past 4 weeks, how often did you experience discomfort or pain during vaginal penetration?
5 = Almost never or never
4 = A few times (less than half the time)
3 = Sometimes (about half the time)
2 = Most times (more than half the time)
1 = Almost always or always
0 = Did not attempt intercourse
18. Over the past 4 weeks, how often did you experience discomfort or pain following vaginal penetration?
5 = Almost never or never
4 = A few times (less than half the time)
3 = Sometimes (about half the time)
2 = Most times (more than half the time)
1 = Almost always or always
0 = Did not attempt intercourse
19. Over the past 4 weeks, how would you rate your level (degree) of discomfort or pain during or following vaginal penetration?
5 = Very low or none at all
4 = Low
3 = Moderate
2 = High
1 = Very high
0 = Did not attempt intercourse
Desire/Arousal Score
Orgasm/Satisfaction Score
Lubrication/Pain Score
MEDICAL HISTORY
Are you currently taking any medicines or supplements (see chart below)
1. Please list the names and dosages of all medications, over-the-counter pills, and hormone pills that you are currently taking. Circle any that you were taking when your hair began to fall out.
2. Please list the names and dosages of all vitamins and natural supplements that you are taking and circle the ones that you were taking when your hair began to fall out:
3. Did you ever have problems (allergic reaction, side-effects) using certain medicines?
Yes
No
Did you ever have problems (allergic reaction, side-effects) using certain medicines? (please specify)
4. Have you used the requested or a similar treatment before?
Yes
No
Have you used the requested or a similar treatment before? (please specify)
5. Do you have any other disease, disorder or medical problem the prescribing doctor needs to know?
Yes
No
Do you have any other disease, disorder or medical problem the prescribing doctor needs to know? (please specify)
6. Did you recently undergo serious surgery?
Yes
No
Did you recently undergo serious surgery? (please specify)
7. Do you suffer from skin sensitivity?
Yes
No
8. Date of last menstrual period?
9. Your blood pressure level
below 90/60
between 90/60 – 150/100
above 150/100
10. Please tell us a few sentences about your current sex life and your main concerns.
DISCLAIMER
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I confirm that the information I have given above is accurate, I understand that giving inaccurate information could compromise the safety and appropriateness of the treatment that the doctor would be prescribing for me.
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I agree to be contacted via email and to The Natural Doctor’s privacy policy (By providing these details you are giving us permission to contact you via these means about your appointments and associated information about your treatment)
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I understand that the BioO range for libido enhancement is a new development and we cannot offer a guarantee of benefit with respect to the treatment prescribed.
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I understand that I will be in charge of administering the prescribed products and supplements. I will confirm and comply with the recommended doses and methods of administration.
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I agree to report to the physicians any adverse reaction or problems that might be related to my treatment. I understand that I need to comply with the recommended dosage.
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I have read and understood all of the above consent. I have had suficcient information given to me about my treatment and that I fully understand what I am signing and hereby request and consent to treatment using hormone supplementation therapy or other therapy offered at The Natural Doctor
Thank you for taking the time to complete your personal form. In order to review the effectivity of our programme, we will be noting down some before and after comments while using our programme. Please note that we might use your comments for promotional purposes. These will always remain anonymous. Thank you!
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