Erectile Dysfunction Intake Form
The medical information you supply is subject to ALL patient/doctor privilege laws
Date of Birth
*
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Employment Status - Employer? Self-Employed? Retired?
Emergency contact
Full Name
Phone Number
Relationship to patient
Parent
Significant Other
Sibling
Child
Friend
Other
MEDICAL HISTORY
Do you have any allergies? Please list
List All Medical Conditions
List All Current Medications/Supplements
Surgical History
Additional Comments
SEXUAL HISTORY
Presenting complaints:
Premature Ejaculation (ED)
Erectile Dysfunction(ED)
Both
Other
If checked other, please describe reason for appointment
How long have you been experiencing this issue. Describe the issue, when it started and how long you have been experiencing this issue:
What have you tried? (check all that apply)
Viagra
Cialis
Levitra
Injections
VED/Pump
Testosterone
GAINSwave or shock therapy
Other
How did it work? Describe any other treatments you have tried.
Did you experience any side effect?
Indicate the BEST NATURAL erection achieved during sexual encounter in the last 3- 6 months (when NOT using Viagra etc)
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)
If masturbate, what is percent From 0 -100% BEST Natural Erection you can achieve during last 6 months (If not applicable, write N/A)
How frequently do you have morning erections?
Daily
Weekly
Monthly
Rarely
Never
If you are experiencing issues with Premature Ejaculation:
Is this a life long problem?
Or is this a recent problem?
If you are experiencing Premature Ejaculation, can you achieve and maintain a full erection until ejaculation occurs?
Yes
No
SOCIAL HISTORY
Social History
Single
Dating
Married
Divorced
Widowed
Do you Smoke
Yes
No
Do you consume alcoholic beverages?
Yes
No
Do you use marijuana, cocaine or other similar drugs?
Yes
No
IIEF/SHIM International Index of Erectile Dysfunction
How do you rate your confidence that you could achieve and keep an erection?
1- Never/Almost never
2- Low
3- Moderate
4- High
5- Very High
When you had erections with sexual stimulation, how often were your erections hard enough for penetration?
1- Never/Almost never
2- A few times (much less than half the time)
3- Sometimes (about half the time)
4- Most times (much more than half the time)
5- Almost always/Always
During sexual intercourse, how often were you able to maintain your erections after you had penetrated (entered) your partner?
1- Never/ Almost never
2- A few times (much less than half the time)
3- Sometimes (about half the time)
4- Most times (much more than half the time)
5 - Almost always / Always
During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?
1- Extremely difficult
2- Very difficult
3- Difficult
4- Slightly difficult
5- Not difficult
When you attempted sexual intercourse, how often was it satisfactory to you?
1- Never/ Almost never
2- A few times (much less than half the time)
3- Sometimes (about half the time)
4- Most times (much more than half the time)
5- Almost always/ Always
Submit
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