New Patient Form for Erectile Dissatisfaction Treatments12345 Patient Information SheetPatient Name:*Date:* MM slash DD slash YYYY Date of Birth:* MM slash DD slash YYYY Age:*Sex:* Male FemaleAddress*City:* City State:* State Zip: ZIP Cell Phone :*Email Address:* We require 24-hour cancellation notice for all appointments. As a courtesy to our clients we send text message appointment reminders the day before your next scheduled appointment. Please note that it is your responsibility to remember your appointment date and time and if there is a less than 24-hour cancellation notice a fee does apply.Emergency contact:Name:*Relationship:*Phone :*How did you hear about us?*Medical HistoryAre you receiving care from other healthcare professionals? Yes NoIf yes, please name them and their specialty:Any surgeries? If yes, lease list:Please list any prescription drugs or medications you are taking Please list any vitamins/herbs/homeopathics/other you are taking: Date of Last Physical Exam MM slash DD slash YYYY Last Blood work MM slash DD slash YYYY Please email us a copy to [email protected] prior to your appointmentDo you know your testosterone level? If so, what is it?Have you seen a neurologist in the past?Allergies:Medication Allergies:Cosmetic Allergies:Latex/Other Allergies:Do you or have you ever had any of the following conditions?Check all that apply:AIDS/HIV Yes NoArthritis Yes NoAuto Immune Disorder Yes NoAsthma Yes NoCancer (Chemo/Radiation) Yes NoDiabetes Yes NoDizziness Yes NoEpilepsy/Seizures Yes NoFainting Yes NoHeart Disease Yes NoHepatitis Yes NoHigh Blood Pressure Yes NoInfection (active) Yes NoKeloid/Hypertrophic Scars Yes NoKidney Disease Yes NoLiver Disease Yes NoMental Disorder Yes NoNeuromuscular Disorder Yes NoRespiratory Issues Yes NoSkin Disease Yes NoStomach Problems Yes NoStroke Yes NoThyroid Disease Yes NoBlood disorders (anemia, porhyria, bleeding disorders) Yes NoOther:Do you smoke? Yes NoIf so how much per day?Do you use recreational drugs? Yes No1. Do you have a decrease in libido (sex drive)? Yes NoIf Yes, how would you rate your libido? 1 (terrible) 2 (poor) 3 (average) 4 (good) 5 (excellent)2. Do you have a lack of energy? Yes NoIf Yes, how would you rate your energy level? 1 (terrible) 2 (poor) 3 (average) 4 (good) 5 (excellent)3. Do you have a decrease in strength and/or endurance? Yes NoIf Yes, how would you rate your strength and/or endurance? 1 (terrible) 2 (poor) 3 (average) 4 (good) 5 (excellent)4. Have you lost height? Yes NoIf Yes, how much height have you lost? 1 (2” or more) 2 (1.5-1.9”) 3 (1-1.4”) 4 (0.5-0.9”) 5 (none-0.4”)5. Have you noticed a decreased “enjoyment of life”? Yes NoIf Yes, how would you rate your “enjoyment of life”? 1 (terrible) 2 (poor) 3 (average) 4 (good) 5 (excellent)6. Are you sad and/or grumpy? Yes NoIf Yes, how would you rate your happiness level? 1 (terrible) 2 (poor) 3 (average) 4 (good) 5 (excellent)7. Are your erections less strong? Yes NoHow strong are your erections? ( 1= extremely weak 5= extremely strong) 1 2 3 4 58. Have you noticed a recent deterioration in your ability to play sports? Yes NoIf Yes, how would you rate your sports ability over the past 4 weeks? 1 (terrible) 2 (poor) 3 (average) 4 (good) 5 (excellent)9. Are you falling asleep after dinner? Yes NoIf Yes, how often do you fall asleep after dinner? 1 (never) 2 (1-2/week) 3 (3-4/week) 4 (5-6/week) 5 (every night)10. Has there been deterioration in your work performance? Yes NoIf Yes, how would you rate your work performance over the past 4 weeks? 1 (terrible) 2 (poor) 3 (average) 4 (good 5 (excellent)If you answered YES to number 1 or 7 or if you answered YES to at least 3 questions in total, you may have low testosterone.How often were you able to get an erection during sexual activity? Almost Never A Few Times (much less than half the time) Sometimes (about half the time) Most Times (much more than half the time) Almost Always or AlwaysWhen you had erections with sexual stimulation, how often were your erections hard enough for penetration (entering your partner)? Almost Never A Few Times (much less than half the time) Sometimes (about half the time) Most Times (much more than half the time) Almost Always or AlwaysWhen you attempted intercourse, how often were you able to penetrate (enter) your partner? Almost Never A Few Times (much less than half the time) Sometimes (about half the time) Most Times (much more than half the time) Almost Always or AlwaysDuring sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner? Almost Never A Few Times (much less than half the time) Sometimes (about half the time) Most Times (much more than half the time) Almost Always or AlwaysDuring sexual intercourse, how difficult was it to maintain your erection to completion of intercourse? Extremely Difficult Very Difficult Difficult Slightly Difficult Not DifficultWhat is your desired outcome from the P-shot procedure? Check all that apply: Increased Libido Better erections Bigger size Better performance Perony’s diseaseHave you done P-shot procedure before? Yes NoIf yes, please specify the date and amount of treatmentsIf yes, did you find it helpful?
