Questions Related to Libido Loss

In order to prescribe treatments for Libido loss our doctor needs some information regarding this specific condition. Please complete the following as accurately as possible.

Do you suffer from decreased libido or low sex drive ? If so, please describe your symptoms.

Yes Sometimes No

Please provide details

Has your Uterus been removed?

Yes No

Have your ovaries been removed?

Yes No

Are you currently taking any hormonal medicines (such as HRT) ? If so please state the exact name and dosage of all treatments taken.

Yes No

Are you currently going through Menopause or are you Post-Menopausal?

Yes No

Are you under the age of 45?

Yes No

Has your doctor determined that your sexual hormone levels are low?

Yes No

Have you ever been diagnosed with breast cancer?

Yes No

When was your last breast check?

Do you suffer from liver disease?

Yes No

Do you suffer from kidney disease?

Yes No

Do you suffer from heart disease?

Yes No

Is there any possibility that you could be pregnant?

Yes No

There is no chance that anyone pregnant can not come into contact with this medication if prescribed to me.

Are you taking warfarin?

Yes No

I understand that I need to take concurrent oestrogen treatment with Intrinsa, and will source that from my regular doctor.

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