Men's Intimate Wellness Intake
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Why are you considering GAINSWave Therapy? (Select at least one)
*
Erectile Performance
Erectile Dysfunction
Peyronie's Disease
Medical History: Select all applicable
*
Diabetes
High Blood Pressure
History of Prostate Cancer
None of the above
Other
Current medication use:
*
Beta-Blockers
SSRIs
Cialis/Viagra
Trimix
None of the above
Please list all current medications, including Testosterone and supplements:
Do you smoke?
*
Yes
No
If yes, how many packs per day?
Do you have a history of smoking?
*
Yes
No
How many alcoholic beverages do you average per night or weekend?
*
What is your occupation?
*
On a scale of 1-10 (10 being the highest level) rate your stress
*
Please list all surgeries, if any:
Please list all allergies, if any:
When was your last physical exam?
*
-
Month
-
Day
Year
Date
Have you ever used Hormone Replacement Therapy? If yes, indicate when, what type, and dosage.
When was the last time Testosterone and PSA were administered? If never, please write "N/A".
Erectile Hardness Score (select one):
*
1: Penis is larger, but not hard
2: Penis is hard, but not hard enough for penetration
3: Penis is hard enough for penetration, but not completely hard
4: Penis is completely hard and fully rigid
SHIM
Please rate each of the following questions on a scale of 1 to 5
How would you rate your confidence that you can get and keep an erection?
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1: Very Low
2: Low
3: Moderate
4: High
5: Very High
When you have an erection with sexual stimulation, how often are your erections hard enough for penetration?
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1: Never
2: A Few Times
3: Sometimes
4: Most Times
5: Always
During sexual intercourse, how often were you able to maintain your erection after you had penetrated your partner?
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1: Never
2: A Few Times
3: Sometimes
4: Most Times
5: Always
During sexual intercourse, how difficult is it to maintain your erection to completion of intercourse?
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1: Extremely Difficult
2: Very Difficult
3: Difficult
4: Slightly Difficult
5: Not Difficult
When you attempt sexual intercourse, how often is it satisfactory for you?
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1: Never
2: A Few Times
3: Sometimes
4: Most Times
5: Always
Is there anything else you would like to make Dr. Arianna Sholes-Douglas aware of at this time?
I certify that the above information is correct to the best of my knowledge. I will not hold my doctor or any members of the staff responsible for any errors or omission that I may have made in the completion of this form
Signature
*
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