Primary Concern
Low libido (low desire for sex)
Trouble with arousal or satisfaction
Difficulty with orgasm
Mood and anxiety affecting sex life
Vaginal dryness or discomfort
I’m not sure – I want a full evaluation
Onset & Frequency
Select
When did you first notice these concerns?
Over a year ago
6–12 months ago
Less than 6 months ago
Select
How often does this concern affect your sex life?
Rarely
Occasionally
Frequently
Every time
Additional Factors
Do you also experience:
Low mood or anxiety
Stress that affects your sex drive
Relationship challenges
Pain with sex
None of the above
Have You Tried Any Treatments Before?
No, I haven’t tried anything yet
Over-the-counter products (lubricants, supplements)
Prescription medications (Addyi, Wellbutrin, etc.)
Counseling or coaching
Other (text box)
Comfort with Prescription Options
Select
Are you open to non-hormonal prescription options?
Yes, I’m open!
I’m interested, but want to learn more
I prefer natural solutions only
Sexual Health Goals
Improve my libido (desire for sex)
Enhance arousal and satisfaction
Support orgasm
Reduce anxiety/stress affecting intimacy
Feel more confident in my sex life
Lifestyle & Health
Select
Are you pregnant or breastfeeding?
Yes
No
Select
Any medical conditions or allergies?
Yes - text box
No
Select
Are you in a relationship?
Yes
No
Name
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