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BC Centre for Sexual Medicine Referral Form HTML

HTML icon BC Sexual Medicine Referral Form.html — HTML, 40 kB (41754 bytes)

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<html>
<head>
	<title>BC Centre for Sexual Medicine Referral Form</title>
	
	<link rel="stylesheet" type="text/css" href="${oscar_image_path}JSMPC.css" />
	
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</head>

<body onload="startUp();" onMouseDown="showButtons();">
	<form method="post" action="" name="FormName" id="FormName" >
	
	
		<div id="page1" style="position: relative; left: 0px; top: 0px; width:750px;" class="pagebreak">
			<img id="BGImage" src="${oscar_image_path}BlankPage.png" width="750">	
			
			
<span style="position:absolute; left:200px; top:5px; font-family:times new roman; font-weight:normal; font-size:20px;"><b><u>CONSULTATION REFERRAL FORM</u></b></span>			

<span style="position:absolute; left:140px; top:50px; font-family:times new roman; font-weight:normal; font-size:18px;"><b>ASSESSMENT AND TREATMENT RECOMMENDATIONS</b></span>			

<span style="position:absolute; left:205px; top:70px; font-family:times new roman; font-weight:normal; font-size:18px;"><b>at BC CENTRE FOR SEXUAL MEDICINE</b></span>	

<span style="position:absolute; left:135px; top:90px; font-family:times new roman; font-weight:normal; font-size:18px;">Suite 500 - 575 West 8th Avenue (at Ash), Vancouver BC V5Z 1C6</span>	
		
<span style="position:absolute; left:210px; top:110px; font-family:times new roman; font-weight:normal; font-size:18px;">Phone: 604-875-8282  Fax: 604-875-8249</span>	

<span style="position:absolute; left:18px; top:148px; font-family:times new roman; font-weight:normal; font-size:16px;"><b>*Please print clearly and complete in full</b></span>	

<span style="position:absolute; left:17px; top:184px; font-family:times new roman; font-weight:normal; font-size:16px;">Date: <input name="Date" id="Date" type="text" class="noborder" style=" width:200px; height:25px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; text-align:left; text-decoration:underline; background-color:white;"  oscarDB=today ><u>(yyyy-mm-dd)</u></span>	

<span style="position:absolute; left:17px; top:235px; font-family:times new roman; font-weight:normal; font-size:16px;"><b>NAME OF PATIENT:</b></span>	

<input name="patient_name" id="patient_name" type="text" class="noborder" style="position:absolute; left:175px; top:232px; width:475px; height:25px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; text-align:left; text-decoration:underline; background-color:white;"  oscarDB=patient_name>

<span style="position:absolute; left:17px; top:285px; font-family:times new roman; font-weight:normal; font-size:16px;">Gender:</span>	

<input name="Gender" id="Gender" type="text" class="noborder" style="position:absolute; left:75px; top:282px; width:200px; height:25px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; text-align:left; text-decoration:underline; background-color:white;"  oscarDB=sex>

<span style="position:absolute; left:280px; top:285px; font-family:times new roman; font-weight:normal; font-size:16px;">PHN:</span>	

<input name="PHN" id="PHN" type="text" class="noborder" style="position:absolute; left:320px; top:282px; width:400px; height:25px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; text-align:left; text-decoration:underline; background-color:white;"  oscarDB=hin>

<span style="position:absolute; left:17px; top:320px; font-family:times new roman; font-weight:normal; font-size:16px;">Age:</span>	

<input name="Age" id="Age" type="text" class="noborder" style="position:absolute; left:65px; top:317px; width:130px; height:25px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; text-align:left; text-decoration:underline; background-color:white;"  oscarDB=age>

<span style="position:absolute; left:200px; top:320px; font-family:times new roman; font-weight:normal; font-size:16px;">Date of Birth:</span>	

<input name="DOB" id="DOB" type="text" class="noborder" style="position:absolute; left:285px; top:317px; width:435px; height:25px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; text-align:left; text-decoration:underline; background-color:white;"  oscarDB=dob>

<span style="position:absolute; left:17px; top:370px; font-family:times new roman; font-weight:normal; font-size:16px;">Telephone Number:<u>(home)</u><input name="HomePhone" id="HomePhone" type="text" class="noborder" style=" width:260px; height:25px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; text-align:left; text-decoration:underline; background-color:white;"  oscarDB=phone><u>(work)</u><input name="WorkPhone" id="WorkPhone" type="text" class="noborder" style=" width:240px; height:25px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; text-align:left; text-decoration:underline; background-color:white;"  oscarDB=phone2></span>

<span style="position:absolute; left:17px; top:402px; font-family:times new roman; font-weight:normal; font-size:16px;">Cell phone or email (if possible) <input name="CelPhone" id="CelPhone" type="text" class="noborder" style=" width:510px; height:25px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; text-align:left; text-decoration:underline; background-color:white;"  oscarDB=cell></span>

<span style="position:absolute; left:17px; top:440px; font-family:times new roman; font-weight:normal; font-size:16px;">Address: </span>

<textarea name="Address" id="Address" class="noborder" style="position:absolute; left:80px; top:442px; width:650px; height:80px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; text-decoration:underline; background-color:white;" oscarDB=address ></textarea>

<span style="position:absolute; left:17px; top:522px; font-family:times new roman; font-weight:normal; font-size:16px;"><b>REFERRING PHYSICIAN:</b><input name="ReferringPhysician" id="ReferringPhysician" type="text" class="noborder" style=" width:350px; height:25px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; text-align:left; text-decoration:underline; background-color:white;"  oscarDB=Provider_name_first_init>Billing#:<input name="Billing#" id="Billing#" type="text" class="noborder" style=" width:120px; height:25px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; text-align:left; text-decoration:underline; background-color:white;"  oscarDB=doctor_ohip_no></span>

<span style="position:absolute; left:17px; top:558px; font-family:times new roman; font-weight:normal; font-size:16px;">GP/FP <input name="GP" id="GP" type="text"  style=" width:14px; height:14px;border: 1px solid #000000;font-weight:bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);" > Psychiatrist <input name="Psych" id="Psych" type="text"  style=" width:14px; height:14px;border: 1px solid #000000;font-weight:bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);" > Gynecologist <input name="Gyne" id="Gyne" type="text"  style=" width:14px; height:14px;border: 1px solid #000000;font-weight:bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);" > Urologist <input name="Uro" id="Uro" type="text"  style=" width:14px; height:14px;border: 1px solid #000000;font-weight:bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);" > Other (specify) <input name="OtherReferralSpecify" id="OtherReferralSpecify" type="text" class="noborder" style=" width:280px; height:25px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; text-align:left; text-decoration:underline; background-color:white;"  value=""></span>

<span style="position:absolute; left:17px; top:590px; font-family:times new roman; font-weight:normal; font-size:16px;">Telephone:<input name="ClinicPhone" id="ClinicPhone" type="text" class="noborder" style=" width:165px; height:25px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; text-align:left; text-decoration:underline; background-color:white;"  oscarDB=clinic_phone>Fax:<input name="clinic_fax" id="clinic_fax" type="text" class="noborder" style=" width:190px; height:25px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; text-align:left; text-decoration:underline; background-color:white;"  oscarDB=clinic_fax>Dr.'s Private Line:<input name="PrivateLine" id="PrivateLine" type="text" class="noborder" style=" width:150px; height:25px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; text-align:left; text-decoration:underline; background-color:white;"  value=""></span>

<span style="position:absolute; left:17px; top:625px; font-family:times new roman; font-weight:normal; font-size:16px;"><b><u>Please check that all have been completed and/or attached:</u></b></span>

<span style="position:absolute; left:17px; top:645px; font-family:times new roman; font-weight:normal; font-size:16px;"><input name="PriorConsults" id="PriorConsults" type="text"  style=" width:14px; height:14px;border: 1px solid #000000;font-weight:bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);" > All potentially relevant prior consultations on this patient (and/or partner)</span>

<span style="position:absolute; left:17px; top:662px; font-family:times new roman; font-weight:normal; font-size:16px;"><input name="Labs" id="Labs" type="text"  style=" width:14px; height:14px;border: 1px solid #000000;font-weight:bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);" > Relevant laboratory data or physical exam findings</span>

<span style="position:absolute; left:17px; top:679px; font-family:times new roman; font-weight:normal; font-size:16px;"><input name="SexualInventory" id="SexualInventory" type="text"  style=" width:14px; height:14px;border: 1px solid #000000;font-weight:bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);" > BC Centre for Sexual Medicine 2 page Sexual Inventory</span>

<span style="position:absolute; left:17px; top:724px; font-family:times new roman; font-weight:normal; font-size:16px;"><b><u>Is this an ...?</u></b></span>

<span style="position:absolute; left:17px; top:741px; font-family:times new roman; font-weight:normal; font-size:16px;">Unsettled Medical-Legal Case</span>

<span style="position:absolute; left:250px; top:741px; font-family:times new roman; font-weight:normal; font-size:16px;">Yes <input name="MedicalLegalYes" id="MedicalLegalYes" type="text"  style=" width:14px; height:14px;border: 1px solid #000000;font-weight:bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);" > No <input name="MedicalLegalNo" id="MedicalLegalNo" type="text"  style=" width:14px; height:14px;border: 1px solid #000000;font-weight:bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);" ></span>

<span style="position:absolute; left:17px; top:758px; font-family:times new roman; font-weight:normal; font-size:16px;">Unsettled ICBC Case</span>

<span style="position:absolute; left:250px; top:758px; font-family:times new roman; font-weight:normal; font-size:16px;">Yes <input name="ICBCYes" id="ICBCYes" type="text"  style=" width:14px; height:14px;border: 1px solid #000000;font-weight:bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);" > No <input name="ICBCNo" id="ICBCNo" type="text"  style=" width:14px; height:14px;border: 1px solid #000000;font-weight:bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);" ></span>

<span style="position:absolute; left:17px; top:775px; font-family:times new roman; font-weight:normal; font-size:16px;">Unsettled WCB Case</span>

<span style="position:absolute; left:250px; top:775px; font-family:times new roman; font-weight:normal; font-size:16px;">Yes <input name="WCBYes" id="WCBYes" type="text"  style=" width:14px; height:14px;border: 1px solid #000000;font-weight:bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);" > No <input name="WCBNo" id="WCBNo" type="text"  style=" width:14px; height:14px;border: 1px solid #000000;font-weight:bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);" ></span>

<div align="center" style="font-family:times new roman; font-size:16px; position: absolute; left:15px; top:805px;">
<table width="700" ><tr><td>
Please note that we do NOT accept patients who have active medical/legal cases.  Such patients may be referred by their lawyer or administrative agency via a SEPARATE letter to a specific physician at our Centre, for an independent medical/legal evaluation (IME). Note: IME's are not funded by MSP.
</td></tr>
<tr><td>
 
</td></tr>
<tr><td><b>
NOTE: <u> We need 3 working days notice to change or cancel an appointment or we may not be able to reschedule.
</td></tr>

</table>
</div>

<span style="position:absolute; left:723; top:905; font-family:times new roman; font-weight:normal; font-size:16px;">1</span>

			
			
					</div>
		<div id="page2" style="position: relative; left: 0px; top: 0px; width:750px;" class="pagebreak">
			<img id="BGImage2" src="${oscar_image_path}BlankPage.png" width="750">

<span style="position:absolute; left:90px; top:5px; font-family:times new roman; font-weight:normal; font-size:20px;"><b><u><i>Sexual Medicine Inventory 1 - for completion by referring physician</i></u></b></span>			
			
<span style="position:absolute; left:15px; top:60px; font-family:times new roman; font-weight:normal; font-size:16px;"><b>Name of Patient:</b><input name="patient_name2" id="patient_name2" type="text" class="noborder" style=" width:370px; height:25px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; text-align:left; text-decoration:underline; background-color:white;"  oscarDB=patient_name>Gender:<input name="Gender2" id="Gender2" type="text" class="noborder" style=" width:85px; height:25px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; text-align:left; text-decoration:underline; background-color:white;"  oscarDB=sex>Age:<input name="Age2" id="Age2" type="text" class="noborder" style=" width:70px; height:25px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; text-align:left; text-decoration:underline; background-color:white;"  oscarDB=age></span>

<span style="position:absolute; left:15px; top:112px; font-family:times new roman; font-weight:normal; font-size:16px;"><b>Name of Partner:</b><input name="NoPartner" id="NoPartner" type="text"  style=" width:14px; height:14px;border: 1px solid #000000;font-weight:bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);" > N/A or <input name="partner" id="partner" type="text" class="noborder" style=" width:302px; height:25px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; text-align:left; text-decoration:underline; background-color:white;"  value="">Gender:<input name="Gender2" id="Gender2" type="text" class="noborder" style=" width:85px; height:25px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; text-align:left; text-decoration:underline; background-color:white;"  value="">Age:<input name="Age2" id="Age2" type="text" class="noborder" style=" width:70px; height:25px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; text-align:left; text-decoration:underline; background-color:white;"  value=""></span>

<span style="position:absolute; left:15px; top:164px; font-family:times new roman; font-weight:normal; font-size:16px;"><u>Types of Sexual Difficulties, Duration:</u></span>			

<textarea name="Difficulties" id="Difficulties" class="noborder" style="position:absolute; left:15px; top:184px; width:710px; height:120px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;" value="" ></textarea>

<span style="position:absolute; left:15px; top:305px; font-family:times new roman; font-weight:normal; font-size:16px;"><u>Patient's sexual response with self-stimulation:</u></span>			

<textarea name="SelfStim" id="SelfStim" class="noborder" style="position:absolute; left:15px; top:325px; width:710px; height:65px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;" value="" ></textarea>

<span style="position:absolute; left:15px; top:390px; font-family:times new roman; font-weight:normal; font-size:16px;"><u>Your Diagnosis:</u></span>			

<textarea name="Dx" id="Dx" class="noborder" style="position:absolute; left:15px; top:410px; width:710px; height:50px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;" value="" ></textarea>

<span style="position:absolute; left:15px; top:458px; font-family:times new roman; font-weight:normal; font-size:16px;"><u>Recent or previous treatment (medications, other professionals) for this sexual concern:</u></span>			

<textarea name="RecentRx" id="RecentRx" class="noborder" style="position:absolute; left:15px; top:475px; width:710px; height:50px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;" value="" ></textarea>

<span style="position:absolute; left:15px; top:523px; font-family:times new roman; font-weight:normal; font-size:16px;"><u>General Medical History of Patient (Surgical, Medical) and any physical findings:</u></span>

<textarea name="GenHx" id="GenHx" class="noborder" style="position:absolute; left:15px; top:540px; width:710px; height:70px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;" oscarDB=medical_history ></textarea>

<span style="position:absolute; left:15px; top:608px; font-family:times new roman; font-weight:normal; font-size:16px;"><u>Psychiatric History (present status and past history)</u></span>

<textarea name="PsycHx" id="PsycHx" class="noborder" style="position:absolute; left:15px; top:625px; width:710px; height:50px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;" value="" ></textarea>

<span style="position:absolute; left:15px; top:680px; font-family:times new roman; font-weight:normal; font-size:16px;"><u>Current Medications and allergies:</u> attached Yes <input name="MedsAttached" id="MedsAttached" type="text"  style=" width:14px; height:14px;border: 1px solid #000000;font-weight:bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);" > No <input name="MedsNotAttached" id="MedsNotAttached" type="text"  style=" width:14px; height:14px;border: 1px solid #000000;font-weight:bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);" > if no please list</span>

<textarea name="CurrentMeds" id="CurrentMeds" class="noborder" style="position:absolute; left:15px; top:700px; width:710px; height:65px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;" oscarDB=druglist_generic ></textarea>

<span style="position:absolute; left:15px; top:763px; font-family:times new roman; font-weight:normal; font-size:16px;"><u>Relevant Medical/Surgical/Psychiatric History of Partner (if applicable)</u></span>

<textarea name="ReleventPartnerHx" id="ReleventPartnerHx" class="noborder" style="position:absolute; left:15px; top:783px; width:710px; height:95px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;" value="" ></textarea>

<span style="position:absolute; left:723px; top:905px; font-family:times new roman; font-weight:normal; font-size:16px;">2</span>

			
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		<div id="page3" style="position: relative; left: 0px; top: 0px; width:750px;" class="pagebreak">
			<img id="BGImage3" src="${oscar_image_path}BlankPage.png" width="750">

<span style="position:absolute; left:250px; top:5px; font-family:times new roman; font-weight:normal; font-size:20px;"><b><u><i>Sexual Medicine Inventory 2</i></u></b></span>			

<span style="position:absolute; left:150px; top:25px; font-family:times new roman; font-weight:normal; font-size:20px;"><b><u><i>for completion by referring physician OR the patient</i></u></b></span>			

<span style="position:absolute; left:15px; top:65px; font-family:times new roman; font-weight:normal; font-size:16px;"><b>Sexual deisre Yes </b><input name="SexualDesireYes" id="SexualDesireYes" type="text"  style=" width:14px; height:14px;border: 1px solid #000000;font-weight:bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);" ><b> No </b><input name="SexualDesireNo" id="SexualDesireNo" type="text"  style=" width:14px; height:14px;border: 1px solid #000000;font-weight:bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);" ><b> Describe level of desire:</b></span>

<textarea name="LevelofDeisre" id="LevelofDesire" class="noborder" style="position:absolute; left:15px; top:85px; width:710px; height:65px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;" value="" ></textarea>

<span style="position:absolute; left:15px; top:150px; font-family:times new roman; font-weight:normal; font-size:16px;"><b>Sexual attraction to: males </b><input name="males" id="males" type="text"  style=" width:14px; height:14px;border: 1px solid #000000;font-weight:bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);" ><b> females </b><input name="females" id="females" type="text"  style=" width:14px; height:14px;border: 1px solid #000000;font-weight:bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);" ><b> other </b><input name="otherattraction" id="otherattraction" type="text"  style=" width:14px; height:14px;border: 1px solid #000000;font-weight:bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);" ></span>

<span style="position:absolute; left:15px; top:200px; font-family:times new roman; font-weight:normal; font-size:16px;"><b>Sexual arousal noted:</b></span>

<span style="position:absolute; left:15px; top:220px; font-family:times new roman; font-weight:normal; font-size:16px;">-in the genitals (erection or vaginal swelling/lubrication) Yes <input name="erectionyes" id="erectionyes" type="text"  style=" width:14px; height:14px;border: 1px solid #000000;font-weight:bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);" > No <input name="erectionno" id="erectionno" type="text"  style=" width:14px; height:14px;border: 1px solid #000000;font-weight:bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);" > Describe</span>

<textarea name="DescribePhysicalArousal" id="DescribePhysicalArousal" class="noborder" style="position:absolute; left:15px; top:240px; width:710px; height:30px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;" value="" ></textarea>

<span style="position:absolute; left:15px; top:270px; font-family:times new roman; font-weight:normal; font-size:16px;">-in the mind (awareness of sexual arousal) Yes <input name="mindyes" id="mindyes" type="text"  style=" width:14px; height:14px;border: 1px solid #000000;font-weight:bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);" > No <input name="mindno" id="mindno" type="text"  style=" width:14px; height:14px;border: 1px solid #000000;font-weight:bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);" > Describe</span>

<textarea name="DescribeMentalArousal" id="DescribeMentalArousal" class="noborder" style="position:absolute; left:15px; top:290px; width:710px; height:65px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;" value="" ></textarea>

<span style="position:absolute; left:15px; top:355px; font-family:times new roman; font-weight:normal; font-size:16px;"><b>For men: </b> presence of firm morning erections? <input name="erectionyes2" id="erectionyes2" type="text"  style=" width:14px; height:14px;border: 1px solid #000000;font-weight:bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);" > No <input name="erectionno2" id="erectionno2" type="text"  style=" width:14px; height:14px;border: 1px solid #000000;font-weight:bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);" ></span>

<span style="position:absolute; left:15px; top:405px; font-family:times new roman; font-weight:normal; font-size:16px;"><b>Orgasmic experience: <b> Yes <input name="orgasmyes" id="orgasmyes" type="text"  style=" width:14px; height:14px;border: 1px solid #000000;font-weight:bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);" > No <input name="orgasmno" id="orgasmno" type="text"  style=" width:14px; height:14px;border: 1px solid #000000;font-weight:bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);" > Comments?</span>

<textarea name="DescribeOrgasm" id="DescribeOrgasm" class="noborder" style="position:absolute; left:15px; top:425px; width:710px; height:65px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;" value="" ></textarea>

<span style="position:absolute; left:15px; top:490px; font-family:times new roman; font-weight:normal; font-size:16px;"><b>For men: </b> ejaculation concerns? Yes <input name="ejaculationyes" id="ejaculationyes" type="text"  style=" width:14px; height:14px;border: 1px solid #000000;font-weight:bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);" > No <input name="ejaculationno" id="ejaculationno" type="text"  style=" width:14px; height:14px;border: 1px solid #000000;font-weight:bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);" > if yes, describe: </span>

<input name="ejaculationconcens" id="ejaculationconcens" type="text" class="noborder" style="position:absolute; left:15px; top:510px; width:710px; height:25px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; text-align:left; text-decoration:underline; background-color:white;"  value="">

<span style="position:absolute; left:15px; top:540px; font-family:times new roman; font-weight:normal; font-size:16px;"><b>Fertility concerns </b> Yes <input name="fertilityConcernsyes" id="fertilityConcernsyes" type="text"  style=" width:14px; height:14px;border: 1px solid #000000;font-weight:bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);" > No <input name="fertilityConcernsno" id="fertilityConcernsno" type="text"  style=" width:14px; height:14px;border: 1px solid #000000;font-weight:bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);" > if yes, describe: </span>

<input name="fertilityDescribe" id="fertilityDescribe" type="text" class="noborder" style="position:absolute; left:15px; top:560px; width:710px; height:25px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; text-align:left; text-decoration:underline; background-color:white;"  value="">

<span style="position:absolute; left:15px; top:595px; font-family:times new roman; font-weight:normal; font-size:16px;"><b>Pain with sexual activity </b> Yes <input name="Painyes" id="Painyes" type="text"  style=" width:14px; height:14px;border: 1px solid #000000;font-weight:bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);" > No <input name="Painno" id="Painno" type="text"  style=" width:14px; height:14px;border: 1px solid #000000;font-weight:bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);" > if yes, describe: </span>

<input name="PainDescribe" id="PainDescribe" type="text" class="noborder" style="position:absolute; left:15px; top:615px; width:710px; height:25px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; text-align:left; text-decoration:underline; background-color:white;"  value="">

<span style="position:absolute; left:15px; top:645px; font-family:times new roman; font-weight:normal; font-size:16px;"><b>Other issues around sexuality </b></span>

<span style="position:absolute; left:325px; top:645px; font-family:times new roman; font-weight:normal; font-size:16px;"> Yes <input name="OtherIssuesyes" id="OtherIssuesyes" type="text"  style=" width:14px; height:14px;border: 1px solid #000000;font-weight:bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);" > No <input name="OtherIssuesno" id="OtherIssuesno" type="text"  style=" width:14px; height:14px;border: 1px solid #000000;font-weight:bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);" > if yes, describe: </span>

<span style="position:absolute; left:15px; top:660px; font-family:times new roman; font-weight:normal; font-size:16px;">( e.g., self esteem, bladder/bowel, sensory or mobility isses )</span>

<textarea name="DescribeOtherIssues" id="DescribeOtherIssues" class="noborder" style="position:absolute; left:15px; top:680px; width:710px; height:65px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;" value="" ></textarea>

<span style="position:absolute; left:15px; top:745px; font-family:times new roman; font-weight:normal; font-size:16px;"><b>General relationship concerns: </b> Yes <input name="Relationshipyes" id="Relationshipyes" type="text"  style=" width:14px; height:14px;border: 1px solid #000000;font-weight:bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);" > No <input name="Relationshipno" id="Relationshipno" type="text"  style=" width:14px; height:14px;border: 1px solid #000000;font-weight:bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);" > if yes, describe: </span>

<textarea name="RelationshipDescribe" id="RelationshipDescribe" class="noborder" style="position:absolute; left:15px; top:765px; width:710px; height:50px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; text-align:left; text-decoration:underline; background-color:white;"  value=""></textarea>

<span style="position:absolute; left:15px; top:815px; font-family:times new roman; font-weight:normal; font-size:16px;"><b>Past history of sexual abuse </b> Yes <input name="Abuseyes" id="Abuseyes" type="text"  style=" width:14px; height:14px;border: 1px solid #000000;font-weight:bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);" > No <input name="Abuseno" id="Abuseno" type="text"  style=" width:14px; height:14px;border: 1px solid #000000;font-weight:bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);" > if yes, describe whether any continuing effects have been adequately addressed, and if so, by which therapist or specialist. </span>

<textarea name="AbuseDescribe" id="AbuseDescribe" class="noborder" style="position:absolute; left:15px; top:855px; width:710px; height:50px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; text-align:left; text-decoration:underline; background-color:white;"  value=""></textarea>

<span style="position:absolute; left:723px; top:905px; font-family:times new roman; font-weight:normal; font-size:16px;">3</span>
			
			

			
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