Peyronie's Disease Questionnaire

Please complete the details below before your initial appointment.

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PATIENT INFORMATION

Name**

Name

First Last

MHSC Number

PHIN Number

Date of birth**

Age**

Address**

Street Address City Province Postal Code

Preferred phone number**

Email**

PEYRONIE’S DISEASE BOTHER DOMAIN QUESTIONNAIRE

Thinking about the last time you had an erection, how bothered were you by any pain or discomfort you may have felt in your erect penis?**

Thinking about the last time you looked at your erect penis, how bothered were you by the way your penis looked?**

Does your Peyronie’s disease make having intercourse difficult or impossible?**

No

Yes

Thinking about the last time you had, or tried to have, intercourse, how bothered were you by your Peyronie's disease?**

Are you having intercourse less often than usual due to your Peyronie’s disease?**

No

Yes

How bothered are you with having intercourse less often?**

PENTOXIFYLLINE SCREENER

Do you have a hypersensitivity or allergy to pentoxifylline or other xanthines such as caffeine, theophylline, and theobromine?**

No

Yes

Please specify**

Have you ever had a heart attack? Do you have a severe coronary artery disease (blockage of the blood vessels in the heart)?**

No

Yes

Do you have a coagulation (bleeding) disorder or a history of bleeding in your stomach, retina, or brain?**

No

Yes

Do you currently have peptic (stomach)ulcers or recent history thereof?**

No

Yes

Do you have liver disease or impairment in your liver functioning? Do you have renal (kidney) disease or impairment in your kidney functioning?**

No

Yes

Do you have low blood pressure? Lower than 90/60?**

No

Yes

Do you have a history of severe cardiac arrhythmias (abnormal heart rhythm)?**

No

Yes

Do you take insulin or oral antidiabetic agents such as glyburide or gliclazide? Are you being treated with anticoagulant therapy?**

No

Yes

Do you take medication for high blood pressure?**

No

Yes

Do you take any type or anticoagulant medication such as: AS (Aspirin), heparin, warfarin (Coumadin), rivaroxaban, (Xarelto), dabigtran (Pradaxa), or apixaban (Eliquis), enoxaparin (Lovenox)?**

No

Yes

Please specify**

Do you take any of the following medications? Cimetidine (Tagamet), Erythromycin, Theophylline?**

No

Yes

Please specify**

Do you take sympathomimetic drugs such as nasal decongestants, appetite suppressants, stimulants for ADD/ADHD, or bronchodilators such as albuterol?**

No

Yes

Please specify**

PENILE CURVATURE INTAKE FORM

What was the first symptom that you noticed with your penis (eg. nodule, curvature, pain, indentation)?**

How long have you had these symptoms for?**

If your symptoms are NOT changing, how long has it been since you last noticed a change?**

Enter "N/A" if not applicable.

What direction does your penis curve when erect?**

Up

Down

Left

Right

How many degrees would you estimate your penis to curve?**

Where is the curve on your penis?**

Near the top of the penis

Top middle of the shaft

Lower middle of the shaft

At the base of the penis

Do you have penile pain with erections?**

No

Yes

Do you recall any buckling injuries during intercourse, or have you had a “penile fracture” previously?**

No

Yes

Do you have a narrowing of a section of your penis like an hourglass?**

No

Yes

Do you have an indentation on your penis?**

No

Yes

Do you experience penile shortening when erect?*

No

Yes

HISTORY OF ERECTILE FUNCTION

What was your best erection prior to the onset of your penile changes? Circle the most accurate number using our 10-point scale**

How would you rate the hardness of your erection when you are NOT using pills, injections or supplements (Viagra, Cialis, Levitra)?**

Penis does not enlarge	Penis is larger, but not hard	Penis is hard, but not hard enough for penetration	Penis is hard enough for penetration, but not completely hard	Penis is completely hard and fully rigid

Please list any medications that you use to help with erections (Viagra, Cialis, Levitra, Staxyn, penile injections, etc)**

If you do use medication for erections, please rate your best erection when using the medication. Circle the most accurate number using our 10-point scale*

How do you describe the sensation of orgasms compared to before penile changes?**

The same

Decreased

Improved

How long does it take you to orgasm from the onset of intercourse on average?**

SEXUAL PARTNER

What is your sexual orientation?**

Heterosexual

Homosexual

Bisexual

Prefer not to answer

Do you currently have a partner?**

No

Yes

Are you able to have intercourse?**

Yes

No

Please specify the reason (eg. no interest, erectile problems, pain)**

Does your partner experience discomfort as a result of the penile curvature?**

No

Yes

IMPACT

How psychologically bothered are you by the changes to your penis?**

Not at all	Mildly bothered	Moderately bothered	Severely bothered

If bothered, do you think you would benefit from a referral to a mental health specialist?**

Yes

No

How impaired do you feel in respect to sexual function?**

Not at all	Mildly impaired	Moderately impaired	Severely impaired

PREVIOUS EVALUATION

Have you ever received any previous treatment for Peyronie’s disease?**

Yes

No

Please describe:*

MEDICAL & SURGICAL HISTORY

Please list all your medical conditions**

Please list any previous surgeries you’ve had**

Has a physician ever diagnosed you with Dupytren’s contractures, Ledderhose’s disease or tympanic sclerosis?**

No

Yes

Have you had a previous inguinal hernia repair?**

No

Yes

MEDICATIONS

Please list all medications that you are currently taking, including the reason, dosage, and frequency (example: Ciprelax, 20mg once a day for anxiety)**

Are you taking any blood thinner such as Aspirin, Plavix (Clopidogrel), Warfarin (Coumadin), Rivaroxaban (Xarelto), Apixaban (Eliquis), Dabigatran (Pradaxa)?**

No

Yes

Type: | Dose: | Frequency:

Do you take or have a supply of ‘Nitro spray’?**

No

Yes

ALLERGIES

Please list all your known drug allergies and specify the type of allergic reactions:*

PERSONAL HISTORY

Do you smoke?**

Never

Previously

Presently

Please quantify the amount per DAY:**

Do you drink alcohol?**

No

Yes

Please quantify the amount per WEEK:**

Do you use any recreational/illicit drugs?**

No

Yes

Type and frequency of use:**

Occupation**

Please rate how stressful your occupation is at present**

Not at all

Midly

Moderately

Very

Signature*

Date*

Peyronie's Disease Questionnaire

PATIENT INFORMATION

PEYRONIE’S DISEASE BOTHER DOMAIN QUESTIONNAIRE

PENTOXIFYLLINE SCREENER

PENILE CURVATURE INTAKE FORM

HISTORY OF ERECTILE FUNCTION

SEXUAL PARTNER

IMPACT

PREVIOUS EVALUATION

MEDICAL & SURGICAL HISTORY

MEDICATIONS

ALLERGIES

PERSONAL HISTORY

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