Erectoguide - Basic evaluation form

Erectoguide - Basic Evaluation form

Fill the basic medical history form
Full Name

First NameLast Name
Country of Residence
Email Address
Height
Weight
In Pounds
What is your age?
Occupation
How long have you been experiencing ED?
Do you wake up in the morning or during the night with an erection?

No erections at all1-2 times per week1-2 times per monthDaily morning erections - but not strongDaily strong morning erections
How your erection problems started ?

SuddenlyGradually
How hard is your erection (hardest one), on a scale of 0-100?
What is your major issue with erection ?

Difficulty in getting (initiating) erectionDifficulty in maintaining erection
You noticed losing the firmness of erection

Before sexual intercourse (foreplay)During sexual intercourse (penetration)
Did you notice low sexual desire or low arousal along with erection issues ?

YesNo
Is your erection issues getting worse time to time or stable?

Getting worseStable condition
Do you have pain with erections, feel a lump or bump in the penis or have penile curvature?

YesNo
Do you have any issues with retracting foreskin of penis / any skin issues in the penis ?

YesNo
Do you have problems with ejaculation or orgasm (climax)?

YesNo
Do you use any type of contraceptives, such as condoms?

YesNo
Do you have premature (early) ejaculation?

YesNo
What about your sexual activity? Is it typically spontaneous or planned?

SpontaneousPlanned
Is adequate foreplay occurring during sexual activity ?

Adequate foreplayNot adequate foreplay
How is your relationship with your partner? Has there been any changes lately?

Some issues with partnerNo special issues
Do you have any feelings of performance anxiety?

AlwaysSometimesNo anxiety issues
Did the onset of ED coincide with a specific event, such as a major operation or a divorce?

YesNo
Do you have any underlying conditions or have you had any surgery on or injury to your pelvic area (means Hip area) ?

YesNo
Do your erections change at different times, like when with a partner, during stimulation by mouth, or with masturbation?

YesNo
What medications or drugs are you currently using? This includes prescription drugs, over-the-counter drugs, herbals, dietary supplements and illegal drugs.
Details of treatment / tests /procedures
Attach reports and results

Cancelof
MEDICAL DETAILS
Check the medical conditions that apply to you

Heart diseaseHigh blood pressureDiabetesHigh cholesterol levelsPsychiatric disordersOther diseases
Details of medical illness
Are you currently taking any medicines ?

YesNo
If any list the medications details below
Mention about your addictions

SmokingAlcohol useDrugs usageOthers
Write in details
Are you often under a lot of stress, or has something recently upset you?

YesNo
Are you taking any drugs for anxiety / depression etc ?

YesNo
CLIENT DECLARATION
I hereby declare that all the above information is true to the best of my knowledge
Client Signature (Use any finger to draw over the screen)

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Erectoguide - Basic Evaluation form