Peyronie's Disease Intake Form
The medical information you supply is subject to ALL patient/doctor privilege laws
Date of Birth
Street Address Line 2
State / Province
Postal / Zip Code
Please enter a valid phone number.
Employment Status - Employer? Self-Employed? Retired?
Relationship to patient:
Do you have any allergies? Please list
List all medical conditions
List all current medications including prescriptions, over-the-counter and supplements
Do you smoke?
Do you consume alcoholic beverages?
Do you use marijuana, cocaine or other similar drugs?
Approximately how long have you been experiencing this problem?
Was the onset of this problem sudden or gradual?
Please describe the condition. When it first began? If you recall a specific injury or event?
Do you recall an injury to your penis whether it was playing sports or during sexual activity?
If Yes, please describe?
Are your erections bent or curved?
Please describe the direction of the bend: Up, Down, Left or Right?
Please describe approximately to what degree is is the penis bent during an erection?
Has the curvature changed during the past 6 months? If yes, please describe the progression of the curvature and how rapidly it is progressing.
Can you feel a lump or scar tissue inside your penis? If yes, please describe size and location.
Has your penis decreased in length since this problem started?
Do your experience pain or discomfort when you have an erection?
Do your experience pain or discomfort during sexual intercourse ?
Can not have intercourse
If you are unable to have intercourse because either the curvature is so extreme or it's too painful, please give details including how long this condition has prevented you from having intercourse.
Have you tried any treatments for Peyronie's Disease in the past?
Have you tried XIAFLEX ® treatment for Peyronie's Disease in the past?
If yes, please describe past treatments for Peyronie's and if they were successful.
Do you have a family history of Peyronie's Disease?
Do you have a family history of Dupuytren's contracture (scar tissue in the hand)?
Do you suffer from Dupuytren's contracture?
On a scale of 0 - 100%, how firm are your natural erections. Are them firm enough for penetration during sexual intercourse?
How frequently do you get morning erections?
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