Peyronie's Disease 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 including prescriptions, over-the-counter and supplements
Surgical History
Additional Comments
SEXUAL HISTORY
Presenting complaints:
Peyronie's Disease
Erectile Dysfunction(ED)
Both
Approximately how long have you been experiencing this problem?
Was the onset of this problem sudden or gradual?
Sudden
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?
Yes
No
If Yes, please describe?
Are your erections bent or curved?
Yes
No
If Yes, please describe?
Please describe the direction of the bend: Up, Down, Left or Right?
Please describe approximately to what degree 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?
Yes
No
Do you experience pain or discomfort when you have an erection?
Yes
No
Do you experience pain or discomfort when you have an erection?
Yes
No
Can not have intercourse
If you are unable to have intercourse because 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?
Yes
No
Have you tried XIAFLEX treatment for Peyronie's Disease in the past?
Yes
No
If you have tried treatments in the past, please describe past treatments for Peyronie's and if they were successful
Do you have a family history of Peyronie's Disease?
Yes
No
Do you have a family history of Dupuytren's contracture (scar tissue in the hands)?
Yes
No
Do you suffer from Dupuytren's contracture ?
Yes
No
On a scale of 0 to 100%, how firm are your natural erections. Are the firm enough for penetration during sexual intercourse?
How frequently do you get morning erections?
Dialy
Weelkly
Monthly
Rarely
Never
Additional comments:
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
Submit
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