IMHS ED Patient Intake Form

IMHS ED Patient Intake Form

Innovative Men’s Health | Bellevue, WA | (425) 455-1700 | innovativehealthsolutions.net — Please complete the information below so your provider can better understand your health history, symptoms, and treatment goals. Your information is kept private and secure.
About You
Full Legal Name

First NameMiddle NameLast Name
Preferred Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Biological Sex

Age
Last 4 of SSN
Marital Status
Street Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code

Primary Phone
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Preferred Contact
Occupation / Employer
Primary State of Residence

Emergency Contact Full Name

First NameLast Name
Emergency Contact Relationship
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
How did you hear about Innovative Men's Health?

Primary reason - Other (describe)
Main goals for treatment

Other medical conditions or details
Surgical and hospitalization history

Drug or medication allergies
Other allergies

Current prescription medications
Vitamins, supplements, peptides, or over-the-counter products

Erectile Function & Prior Treatment
How long have you been experiencing erectile difficulties?
Onset of problem
Do you still get morning / nocturnal erections?
How often were you able to get an erection during sexual activity?
When you had erections, how often were they hard enough for penetration?
How often were you able to maintain your erection after penetration?
How difficult was it to maintain your erection to completion of intercourse?
How do you rate your confidence that you could get and keep an erection?
How satisfied have you been with your overall sexual relationship?

Additional Symptom Severity (0 = none, 10 = severe)
Morning fatigue / lack of energy
Low motivation / drive
Brain fog / concentration
Erectile difficulties
Reduced morning erections
Irritability / mood swings
Difficulty building/maintaining muscle
Increased body fat (especially belly)
Sleep quality issues
Performance anxiety / sexual confidence
Relationship stress related to ED

Height
Current Weight
Goal Weight
Waist
Typical Blood Pressure
Exercise days/week
Exercise - Types & details
Average sleep hours/night
Sleep quality (1-10)