Erectile Dysfunction New Patient Information Form
Erectile Dysfunction New Patient Information Form
NAME: _____________________________________________________________
Last First Middle
PATIENT HISTORY
AGE: ________
Over the past 30 days, how often have you had partial or full erections when you were sexually stimulated in any
way? (circle one)
0-did not engage in any sexual activity
1-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
Over the past 30 days, when you had erections, how often were the erections firm enough to have sexual relations?
(circle one)
0-did not engage in any sexual activity
1-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
When you attempted sexual intercourse, how often were you able to penetrate (enter) your partner? (circle one)
0-did not attempt intercourse
1-almost never
2-a few times (much less than half)
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? (circle one)
0-unable to attempt intercourse
1-extremely difficult
2-very difficult
3-difficult
4-slightly difficult
5-not difficult
When you attempted sexual intercourse, how often was your erection satisfactory in your opinion? (circle one)
0-did not attempt intercourse
1-almost never/never
2-a few times (much less than half )
3-sometimes (about half the time)
4-most times (much more than half the time)
5-almost always/always
How would you rate your level of sexual desire? (circle one)
1-very low/none at all 2-low 3-moderate 4-high 5-very high
What is the quality of the best erection you have experienced during the night or upon awakening in the morning
during the past month?
1-none at all 2-partial (less than half) 3-partial (better than half) 4-full erection
What is the rigidity of your penis upon achieving orgasm? (circle one)
1-unable to achieve orgasm
2-no erection at all
3-partial (equal to or less than half erect)
4-partial (better than half erect)
5-full erection
Do you have an active sexual partner at this time? (Wife, Girlfriend, Other, None): _____________
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Do you experience any pain with erections? YES NO (Circle One)
Are or were your erections abnormally bent? YES NO (Circle One)
If so, Which direction is it bent? (Up, Down, Left, Right): ___________
How many degrees is the bend? ________
Have you noted any change in the bend during the past six months? YES NO (Circle One)
PREVIOUS EVALUATION:
Have you had your testosterone level measured? YES NO (Circle One)
If so, what were the results? (Normal, Abnormal, Don’t know): _______________
Have you undergone a penile blood flow study? YES NO (Circle One)
If so, What was the result? (Normal, Abnormal, Do not know): ___________
Have you undergone testing of erections during sleep? YES NO (Circle One)
If so, What was the result? (Normal, Abnormal, Do not know) ____________
PREVIOUS TREATMENT:
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RISK FACTORS FOR ERECTILE DYSFUNCTION:
Are you being treated for diabetes mellitus? YES NO (Circle One)
If so, which treatment method are you using to control your sugar? (Circle one)
Diet Pills Insulin
Are you being treated for high blood pressure? YES NO (Circle One)
Are you being treated for elevated blood cholesterol level? YES NO (Circle One)
Do you have heart disease? YES NO (Circle One)
Have you ever had a stroke? YES NO (Circle One)
Have you been told that you have hardening of the arteries? YES NO (Circle One)
Are you or have you been treated for depression? YES NO (Circle One)
FAMILY HISTORY:
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PHYSICAL EXAMINATION
(To be filled out by Physician)
TESTES EXAM:
RIGHT LEFT
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LABORATORY TESTS:
TREATMENTS:
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