North Bay Naturopathic Clinic

Supplemental Adolescent Intake Male

Name:
Birthday:
Address:
Email Address:

Male Reproductive

At what age did you notice testicular and penile growth?
Have you ever had a hernia?
Have you ever noticed any testicular masses?
Have you experienced testicular pain?
Are you sexually active?
Have you ever had a sexually transmitted disease?
Have you ever noticed any penile discharge?
What is your sexual preference?