MALE EXAMINATION FORM

Date: / /

TIME OF DAY: AM / PM

EXAMINATION SPECIALIST:

EXCEPT FOR GOWN/PAPER SHORTS, PATIENT MUST BE COMPLETELY NUDE
(INCLUDING JEWELRY AND WATCHES)


NAME OF PATIENT:

Age: Marital/relationship status:

Sexual orientation: HETERO HOMO BI
If HOMO or BI, is patient dominate, submissive, or versatile?

Brief sexual history:














Total number of sexual partners in life?

Age at first sexual experience?

Age and description of first homosexual experience:


Oral temperature C / F Pulse

Blood Pressure /


NEUROLOGICAL EXAM

Have patient sit up on table.

Complete neurological upper body / eye exam. List any abnormalities or areas of concern:



Have patient stand.

Complete neurological lower body exam. List any abnormalities or areas of concern:




GENERAL EXAMINATION EXCEPT FOR GENITALS

CHEST/ARMS/STOMACH

Have patient lie in supine position.

List any abnormalities or areas of concern:

Does the patient appear to like a light stroking (include the arms and the hands)? YES / NO
Do his nipples respond to the touch? YES / NO
Does he like them to be: Pinched? YES / NO Pulled? YES / NO
Is his abdominal area sensitive? YES / NO
Does the sensitivity extend downward into his groin? YES / NO
Has the patient achieved an erection? YES / NO / PARTIALLY
Has pre-ejaculation fluid been expressed? YES / NO

LEGS

List any abnormalities or areas of concern:

Perform range-of-motion exam. List any abnormalities or areas of concern:


Does the patient appear to like a light stroking? YES / NO
Are his thighs sensitive to the touch? YES / NO
Does he like his feet touched: YES / NO Tickled? YES / NO
Does the sensitivity extend upward into his groin? YES / NO
Has the patient achieved an erection? YES / NO / PARTIALLY
Has pre-ejaculation fluid been expressed? YES / NO


BACK

Have patient lie in prone position.

List any abnormalities or areas of concern:


Does the patient appear to like a light stroking of back? YES / NO
Has the patient achieved an erection? YES / NO / PARTIALLY
Has pre-ejaculation fluid been expressed? YES / NO

LEGS

List any abnormalities or areas of concern:


Does the patient appear to like a light stroking? YES / NO
Has the patient achieved an erection? YES / NO / PARTIALLY
Has pre-ejaculation fluid been expressed? YES / NO

BUTTOCKS

List any abnormalities or areas of concern:


Does the patient appear to like a light stroking? YES / NO
Describe the appearance and muscle tone of buttocks:

Slap both buttocks with open palm and with force, then grab forcefully with both hands. Wait for any appearance
of welts or swelling. Describe appearance:


Have patient reach back and spread cheeks. Describe appearance and quality of anus:


Have patient spread legs, reach down and push genitals between thighs. Describe the appearance of genitals:


Pull on genitals with hand, describe their quality (firm, flaccid, etc.):

Has the patient achieved an erection? YES / NO / PARTIALLY
Has pre-ejaculation fluid been expressed? YES / NO



GENITAL EXAMINATION

Have patient turn over into supine position, then lift gown or remove shorts.
If necessary, shave or trim pubic hair before continuing exam.

List any obvious abnormalities or areas of concern:



PENIS
Describe the appearance and quality of penis:


Is penis veiny?: YES / NO
Large glans? YES / NO
Pubic hair growth: LIGHT THICK SHAVED/TRIMMED
Penis circumcised: YES / NO
If uncircumcised, describe foreskin:


Abnormal discharge: YES / NO
Describe smell of penis:


Size (when flaccid):
Short & close to the body
Long and thick
Long and narrow
Penis responsive to touch: YES / NO
Forcefully squeeze penis. Rebound acceptable? YES / NO
Has the patient achieved an erection? YES / NO / PARTIALLY
Has pre-ejaculation fluid been expressed? YES / NO

Using whatever means required, force penis to an erect state.

Describe appearance of erect penis:


Does patient appear to enjoy penis being forced to erect state?: YES / NO
Describe appearance of patient while being forced to erection:


Has pre-ejaculation fluid been expressed? YES / NO

TESTICLES

Have patient bend knees and pull towards ceiling, feet still on table. If necessary, have patient pull knees to chest,
to facilitate exam of testicles.

Room temperature o C / F
Is the scrotal sac extended? YES / NO
Sensitivity? Light touching acceptable
Light squeezing acceptable
Firm squeezing acceptable
Palpate for growths. Describe any here:


Pull on scrotum, both sides at once and also one at a time. Describe their elasticity:


Has the patient achieved an erection? YES / NO / PARTIALLY
Has pre-ejaculation fluid been expressed? YES / NO

PERINEUM

Have patient remain in knees-to-chest position, then later have patient turn over onto hands and knees.

Describe appearance of the area:


Is this area shaven, trimmed, or natural:
Is this area sensitive to the touch? YES / NO
Does the patient respond favorably? YES / NO
Has the patient achieved an erection? YES / NO / PARTIALLY
Has pre-ejaculation fluid been expressed? YES / NO

ANUS/RECTUM/PROSTATE

The patient may be put into prone or hands-and-knees position as required.
Have patient reach back and spread buttocks as required.
Patient may also have to lower chest to table while on knees as required.

ANUS
POSITION USED:
Describe appearance and quality of anus:


Is the general condition acceptable? YES / NO
Is it responsive to the touch? YES / NO
Is the anal sphincter firm? YES / NO
Does the patient appear to enjoy anal stimulation? YES / NO
Has the patient achieved an erection? YES / NO / PARTIALLY
Has pre-ejaculation fluid been expressed? YES / NO

RECTUM
POSITION USED:
Describe quality of rectum:


Patients last bowel movement:
Is the general condition acceptable? YES / NO
Is it responsive to the touch? YES / NO
Is the rectal muscle tight? YES / NO
Is there satisfactory tone to the rectal muscle? YES / NO
Does the patient appear to enjoy rectal stimulation? YES / NO
Has the patient achieved an erection? YES / NO / PARTIALLY
Has pre-ejaculation fluid been expressed? YES / NO

PROSTATE
POSITION USED:
Describe quality of prostate:


Was prostate easily found: YES / NO
Does stimulation of prostate result in any or more pre-ejaculate expression: YES / NO
Does patient appear to enjoy prostate stimulation: YES / NO
Has the patient achieved an erection? YES / NO / PARTIALLY


ENEMA (OPTIONAL)
POSITION USED:

Was patient administered an enema?: YES / NO
If YES, what type? Fleet Disposable Enema bag (1,000 cc)
Was the patient's penis erect when you began the enema procedure? YES / NO
Was the patient's penis erect during the enema procedure? YES / NO
Was the patient's penis erect after expulsion of the enema? YES / NO
Did the patient appear to be aroused by the act of having an enema administered? YES / NO
Please describe any further rectal or prostate examination(s) that were conducted after expulsion of the enema.



PRE-ORGASM RECTAL TEMPERATURE CHECK

Have patient lie prone, and then spread his buttocks for check.

Temperature: C / F
Was patient sexually aroused by procedure? If so, describe arousal:
Penis erect? YES / NO
Has pre-ejaculation fluid been expressed? YES / NO


MASTURBATION EXHIBITION SESSION AND EJACULATE COLLECTION

Masturbation must be witnessed but examination specialist/others may not assist. During this time, you may also
ask patient further questions about his sexual fetishes/topics.

Read this statement to the patient verbatim:

At this time, you will be observed masturbating UP TO BUT NOT THROUGH ejaculation. Please proceed
as you normally or typically would if you were masturbating alone and without any devices or props. If
possible, please verbally describe what you would normally be envisioning/fantasizing while
masturbating. Please let your health care professional know when you are approaching ejaculation and
then stop masturbating. Do you have any questions?

Time patient began to masturbate: AM / PM

Did patient exhibit any signs of apprehension while the above statement was being read? YES / NO
Was the patient hesitant to masturbate in your presence? YES / NO
In what position(s) did the patient masturbate?


Did the patient talk of anything in general while masturbating? YES / NO
If YES, what did the patient discuss?


What specific fantasies or visions did patient relate that he typically thinks about during masturbation?


Did the patient fondle or manipulate any other parts of his body while masturbating? YES/ NO
If YES, what part(s) of the body?


Did patient exhibit appearance of pre-ejaculate during masturbation? YES / NO
If so, characteristics of pre-ejaculate:


Did patient taste pre-ejaculate?: YES/NO


Did patients body exhibit signs of impending ejaculation (skin flushing, body spasms, moaning, etc.)?
If so, what were they?:


EJACULATE COLLECTION

Have patient remove any gown or shorts.

Read this to the patient verbatim:

At this time, you will be sexually stimulated in a manual fashion through orgasm, in order to collect an
ejaculate specimen. Your healthcare professional will discuss with you the best position in which to
undertake this task. You may be required to be stimulated via any or all your genitals and buttocks or
anus. Devices such as sex toys may also be used. Please let your healthcare professional know in
advance when you are going to ejaculate, so he may properly and completely collect your ejaculate. You
may be required to taste your own ejaculate during and after this session. Do you have any questions?

Assist the patient into whatever position is most comfortable for him, standing or on hands-and-knees are the
most preferred positions.

Describe the patient while being stimulated and during ejaculation:


Describe the force of the ejaculation:


Ejaculate characteristics: MILKY CLEAR THICK RUNNY STRINGY

Describe the quality, appearance, smell, and taste of the ejaculate:



Ejaculate collection: CONDOM SLIDE DISH
If the ejaculate was collected by a CONDOM, when did the patient place on penis?

Approximate volume of ejaculate:


Other physical descriptions of ejaculate:


Last time patient ejaculated prior to this session
Was it through masturbation? YES / NO
If NO, ask patient to describe


Recommendations for further treatment:














NAME OF MALE EXAMINATION SPECIALIST:

SIGNATURE OF MALE EXAMINATION SPECIALIST:


DATE: / / TIME: AM / PM