PEYRONIE’S DISEASE

PEYRONIE’S DISEASE

PATIENT QUESTIONNAIRE (Version 06.08.23)
Name*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
1. Are you currently receiving treatment for Peyronie’s disease?*

YesNo
2. What has been the maximal degree of penile curvature you have noted pre-treatment?*
3. What treatment are you currently pursuing or have most recently pursued? (May select more than one)*

Vacuum deviceInjections (e.g., Xiaflex/Collagenase)Penile plicationExcision of plaque and graftingPenile prosthesisNone of the above
4. For how many years have you been treated for Peyronie’s disease?*
5. How satisfied are you with your current treatment?*

Very dissatisfiedSomewhat dissatisfiedNeither satisfied nor dissatisfiedSomewhat satisfiedVery satisfied
6. What is your current penile curvature in degrees? (see diagram)*
Men with Peyronie’s disease may have problems during vaginal intercourse.

The questions below ask about the severity of any problems that you may be having during vaginal intercourse.

For each problem below, please check the number that best describes how severe the problem was THE LAST TIME YOU HAD PENETRATIVE (VAGINAL OR ANAL) INTERCOURSE.

PLEASE CHECK ONE NUMBER FOR EACH QUESTION. If you did not experience the
problem, check 0.

Problem*

	None (0)	Mild (1)	Moderate (2)	Severe (3)	Very Severe (4)
1. Concern about damaging penis while having penetrative intercourse.
2. Bending or collapsing of penis while having penetrative intercourse.
3. Trouble inserting erect penis into partner’s vagina or anal.
4. Difficulty with some positions that you used to enjoy when having penetrative intercourse.
5. Awkwardness with some positions that you used to enjoy when having penetrative intercourse.
6. Discomfort with some positions that you used to enjoy when having penetrative intercourse.

Thinking of your last erection or the last time you had penetrative intercourse, please indicate the level of pain or discomfort you felt.

PLEASE CHECK ONE NUMBER FOR EACH QUESTION.
If you felt no pain or discomfort, check 0.
7. In the LAST 24 HOURS, how much pain or discomfort have you felt in your penis when it was NOT erect? Please answer the LAST 24 HOURS only.*

1

2

3

4

5

6

7

8

9

10

1 is No pain o Discomfort, 10 is Extreme pain or Discomfort
8. Thinking about the LAST TIME you were erect, how much pain or discomfort did you feel in your penis when it was erect? Please answer for the LAST TIME YOU HAD AN ERECTION.*

1

2

3

4

5

6

7

8

9

10

1 is No pain o Discomfort, 10 is Extreme pain or Discomfort
9. Thinking about the LAST TIME you had penetrative intercourse, how much pain or discomfort did you feel in your penis when having vaginal intercourse? Please answer for the LAST TIME YOU HAD PENETRATIVE INTERCOURSE.*

1

2

3

4

5

6

7

8

9

10

1 is No pain o Discomfort, 10 is Extreme pain or Discomfort
Men with Peyronie’s disease may have problems with erection and/or vaginal intercourse. These problems can be bothersome for some men and not for others.

PLEASE MARK ONE BOX FOR EACH QUESTION.
10.Thinking about the LAST TIME you had an erection, how bothered were you by any pain or discomfort you have felt in your erect penis? Please answer for the LAST TIME YOU HAD AN ERECTION.*

DID NOT feel any pain or discomfort – Please go to question 11.Felt pain or discomfort and I was: Not at all botheredFelt pain or discomfort and I was: A little bit botheredFelt pain or discomfort and I was: Moderately botheredFelt pain or discomfort and I was: Very botheredFelt pain or discomfort and I was: Extremely bothered
11.Thinking about the LAST TIME you looked at your erect penis, how bothered were you by the way your penis looked?*

DID NOT feel any pain or discomfort – Please go to question 12.Felt pain or discomfort and I was: Not at all botheredFelt pain or discomfort and I was: A little bit botheredFelt pain or discomfort and I was: Moderately botheredFelt pain or discomfort and I was: Very botheredFelt pain or discomfort and I was: Extremely bothered
12.Does your Peyronie’s disease make having penetrative intercourse difficult or impossible?*

Yes – Please go to question 13.No – Please go to question 14.
13.Thinking about the LAST TIME you had or tried to have penetrative intercourse, how bothered were you by your Peyronie’s disease? Felt pain or discomfort and I was:

Not at all botheredA little bit botheredModerately botheredVery botheredExtremely bothered
14.Are you having penetrative intercourse LESS OFTEN than you used to due to your Peyronie’s disease?

Yes – Please go to question 13.No – Please go to question 14.
15.How bothered are YOU with having penetrative intercourse less often? Felt pain or discomfort and I was:*

Not at all botheredA little bit botheredModerately botheredVery botheredExtremely bothered
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