PATIENT QUESTIONNAIRE

PATIENT QUESTIONNAIRE
Date

Month Day Year
Date
1. PERSONAL HISTORY
Name *

First Name Last Name
Email
example@example.com
Occupation
example@example.com
Date of Birth
Marital Status
2. MEDICAL HISTORY
Please check any medical conditions that you have, past or present:

Diabetes Blocked Artery HIV/AIDS Bowel Problems Testicular Disease Bleeding Disorder Hypertension Liver Disease Stroke Arthritis Prostate Cancer High Cholesterol Hepatitis Parkinson's Disease Peyronie's Disease Prostate Enlargement Heart Disease Kidney Disease Multiple Sclerosis Depression Heart Attack Thyroid Disease Epilepsy Neurosis STD
Any Other Past or Present Medical Conditions?
SURGERY? List All Past Surgical Procedures:
FAMILY HISTORY: Please indicate if you have a family history of:

Diabetes Heart Problems Cancer Hypertension
Any Other Disease History or Medical Conditions in Your Family?
INJURIES? Indicate any history of injury to the following areas:

Head Back Pelvis Other
If checked other above, please explain injury
SOCIAL HISTORY: Indicate if you
Smoke?
Drink?
Recreational Drug Use?
ALLERGIES? List all known allergic reactions to medications:
MEDICATIONS? List all current medications taken and doses
Name of your Primary Care Physician
When was your last physical check-up? Describe any significant findings from last physical check-up:
SEXUAL HISTORY: Please indicate your primary concern(s)

Erection Problems Premature Ejaculation Both
ERECTION PROBLEMS:
When did you first notice the problems?
Did it start suddenly or gradually?
Has it been getting worse?

YES NO
Has it been consistent or sporadic?
When was the last time you consistently achieved and maintained a full erection for sexual penetration? Please elaborate:
Do you have problems controlling your ejaculation since the onset of ED?

YES NO
Indicate the BEST erection achieved during sexual encounter, in the last 3 - 6 months

50% (unable to penetrate) 65% (able to penetrate but with difficulty most of the time) 80% (able to penetrate fairly easily most of the time) 90% (almost complete) 100% (rock hard)
Indicate how often you can achieve this BEST erection:

Rarely Sometimes Most of the time
Indicate how frequently you experience Morning Erections times/week
These Morning Erections are:

STRONG and Lasting or Partial and Short-lived
Indicate your best masturbatory erections in the last 6 months, using the scale above blanks %
What in your opinion has caused your problem?
What treatments have you tried? Indicate success and adverse effects if any?
What do you wish to achieve from this consultation?
PREMATURE EJACULATION (PE)

Please fill this section out only if you suffer from premature ejaculation problems, if not skin and submit completed form
Please indicate if Premature Ejaculation is:

A life long problem that remains essentially the same, or A life long problem that has become worse recently , or A recent problem
Describe below how long the problem of PE has been going on and elaborate on the experience?
During foreplay, could you achieve and maintain a full erection until you ejaculate

Yes No
On average, how long does it take you to ejaculate after penetration? blanks minutes.
How long does do you wish to last to satisfy your partner?minutes
What in your opinion has caused your PE problem?
What treatments have you tried for PE? Indicate success and adverse effects if any?
What do you wish to achieve from this consultation for your PE issue?
Should be Empty:

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PATIENT QUESTIONNAIRE

1. PERSONAL HISTORY

2. MEDICAL HISTORY

SOCIAL HISTORY: Indicate if you

ERECTION PROBLEMS:

PREMATURE EJACULATION (PE)