Male Sexual Dysfunction, Impotency, Penile Implant

testicular enhancement, scrotal enhancement, erectile dysfunction

Penile enlargement Penis Augmentation

Testicular enhancement Scrotal Enlargement

Erectile Dysfunction

Penile reconstruction

Peyronie's Disease

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PLEASE TAKE THE TIME TO COMPLETE THIS QUESTIONNAIRE. YOUR ANSWERS WILL ALLOW US TO MAKE RECOMMENDATIONS FOR YOUR CARE AS WELL AS HELP US GATHER NEW INFORMATION RELATING TO ERECTILE DYSFUNCTION. PLEASE ANSWER ALL QUESTIONS. THANK YOU FOR YOUR COOPERATION.

NOTE: THIS QUESTIONNAIRE WILL BE MAINTED IN THIS OFFICE AS A PART OF YOUR PATIENT HISTORY CHART, AND WILL REMAIN CONFIDENTIAL IN NATURE.

ERECTILE DYSFUNCTION DATA BASE

1.Today’s date:

2.First Name :

Middle Name :

Last Name :

3.Date of Birth:

4.Marital Status:

How many years have you been married?
Do you have a steady sexual partner?

5.Number of biological children :

6.Ages of biological children :

7.Ethnic/Racial background :

8.Occupation :

9.Does your present or past occupation or your hobbies expose you to any hazardous chemicals, fumes, or radiation?

Which One ?

HABITS :

10.Are you currently taking any medications prescribed by a doctor (including eye drops and skin preparations)?

11.Are there any over-the-counter medications that you use regularly?

list:

12.Have you ever smoked cigarettes?

13.Do you exercise regularly (at least once weekly)

The number of hours per week you engage in vigorous exercise:

hours weekly.

14.Have you had an alcoholic beverage within the last 24 hours?

15.Have you ever had a drinking problem?

16.Have you ever experimented with illegal drugs?

17.Have you ever had a problem with dependency on prescription or illegal drugs?

PAST MEDICAL AND SURGICAL HISTORY

18.Please check if you have ever had any of the following conditions:

a. Diabetes mellitus
b. High blood pressure
c. Cancer
d. Liver disease
e. Kidney disease
f. Coronary artery disease
g. Thyroid disease
h. Hemochromatosis
i. Myotonic dystrophy
j. Spinal cord injury
k. Prostate surgery
l. Bowel surgery

19.List any operations you have had & include the dates on which you had them:

20. Have you ever received radiation, x-ray, or Cobalt therapy (usually given for cancer treatment)?

Describer circumstances:

22. Have you ever had any injuries to your groin, scrotum, or penis

23. Have you ever had the mumps?

At what age:

years of age

24. Have you taken sulfa drugs for more than 1 month? (Usually given for acne or urinary infections)

OTHER SYMPTOMS

25. Do you have frequent or severe headaches?

describe:

26. Do you have double vision?

27. Do you have trouble seeing to either side?

28. Do you have enough energy to get through a typical day

29. Do you sleep well at night?

30. Has your shoe size changed since you were 20 years old?

by how many sizes?

31. Do you have difficulty adjusting to changes in temperature?

The problem is with:

32. How old were you when you developed pubic hair

33. Have you ever had swelling or tenderness of your breasts?

34. At what age did you gain the most height?

Years old

35. Have you ever seen a psychologist, psychiatrist, or counselor?

please indicate why and when:

36. Do you have any personal problems that might be interfering with your sexual or job performance?

Please describe:

SEXUAL HISTORY

37. At what age did you first have an erection?

Years

38. Do you have erections currently?

Is the quality?
When your penis is erect, if you stand up, does it point to:

39. Does your ability to have erections vary with different sexual partners?

40. Do you ever have an erection during the night or when you wake up in the morning?

41. Do you have any concerns regarding the size of your penis?

42. Are you able to have a climax or an orgasm?

43. Does semen (fluid) come out the end of your penis when you have an orgasm?

44. Can you masturbate to climax?

does your penis get hard at this time?

45. Do you have or have you ever had premature ejaculations? (unintentional ejaculation or climax prior to penetration or shortly afterwards)

46. Does reaching a climax seem to take a long time?

47. Is your climax or orgasm ever painful?

48. Is sensation (feeling) in your penis normal?

49. Do you think that your level of interest in sexual relations (how often you feel "horny") is:

50. Do you avoid having sexual relations even though the desire (a horny feeling) is present?

51. Does your primary sex partner seem to have a level of interest in sex that is:

52. Does your primary sex partner get a climax or orgasm during sexual activity or intercourse?

53. Which of the following best describes the attitude of your wife or primary sex partner towards your sexual problem?

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