Men's Sexual Health Registration

Please complete the details below before your initial appointment. Thanks.

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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**

FAMILY DOCTOR INFORMATION

Family Doctor**

Doctor's Phone

Doctor's Location or City

Do you consent to our office communicating with your doctor?**

Yes

PERSONAL HISTORY

Occupation**

Relationship status**

Number of children**

How often do you exercise in a week and for how much each time?*

Do you smoke?**

Yes

Please quantify the amount per DAY:

Do you drink alcohol?**

Yes

Please quantify the amount per WEEK:

Do you use any recreational/illicit drugs?**

Yes

Type and frequency of use:

Do you use or have used anabolic steroids in the past?**

Yes

If yes, please specify type, frequency of use, and the time the last anabolic steroid use :

MEDICAL & SURGICAL HISTORY

Do you have a history of heart disease, congestive heart failure, high blood pressure, elevated cholesterol?**

Yes

Please specify:

Do you currently have a pacemaker, Implantable Cardioverter Defibrillator (ICD), or any other forms of internal/implantable electrical device in your body?**

Yes

Please specify the type of the electrical device and its location:

Do you have a history of metabolic disease such as Diabetes Mellitus?**

Yes

Please specify:

Do you have a history of neurological disorder such as spinal cord injury, head trauma, brain tumour, stroke, mini-stroke/TIA, Parkinson’s disease, Multiple Sclerosis, Epilepsy, etc.?**

Yes

Please specify:

Do you have any history of pelvic fracture or trauma?**

Yes

Please specify the time and the nature of the injury:

Do you have a known or suspected history of prostate cancer?**

Yes

If yes, please specify:

Do you have a history of abnormal prostate exam, Prostatic Hyperplasia (BPH), elevated PSA?**

Yes

If yes, please specify:

Do you have a history of prostate biopsy?**

Yes

If yes, please specify:

Have you ever had TURP surgery for benign prostatic hyperplasia (BPH)?**

Yes

What year?

Have you ever had a history of chemotherapy or radiation therapy?**

Yes

Please specify:

Do you have a history of trauma to the testicles, testicular torsion, orchitis, or undescended testicles?**

Yes

If yes, please specify:

Do you have a history or symptoms of low testosterone (hypogonadism) such as low libido or sex drive, reduced morning erection, lack of energy, etc.?**

Yes

Are you currently on testosterone therapy?**

Yes

If yes, please specify the type, dosage and frequency.

Have you ever had a current or past history of low platelet count?**

Yes

What is the most recent platelet level?

Have you ever had a current or past history of anemia (low hemoglobin count)?**

Yes

What is the most recent hemoglobin level?

Do you have a history of bleeding disorder or hematological disorder (e.g. leukemia, sickle cell anemia)?**

Yes

Please specify:

Do you have a history of thickened blood? (Polycythemia)**

Yes

If yes, please specify:

Do you have current or past history of genital warts (HPV infection)?**

Yes

When was the last episode?

Do you have current or past history of genital herpes (HSV infection)?**

Yes

When was the last episode?

Have you tested positive for human immunodeficiency virus (HIV)?**

Yes

If yes, please specify:

Have you tested positive for tuberculosis (TB)?**

Yes

If yes, please specify:

Have you tested positive for hepatitis (A, B or C)?**

Yes

If yes, please specify:

Do you have a history of depression, anxiety, bipolar disorder, or other psychological disorders?**

Yes

Please specify:

Do you have a history of obstructive sleep apnea?**

Yes

Are you currently on CPAP therapy?

Do you have any history of malignancy (cancer)?**

Yes

Please specify:

Do you have any other medical history that is not included in the above list?**

Yes

Please specify:

Do you have any other significant surgical history that was not included in the above list?**

Yes

Please specify:

MEDICATIONS

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

Yes

Type: | Dose: | Frequency:

Do you have current or past history of Finasteride use?**

Yes

What dosage/frequency?

Do you have a history or Androgenic Anabolic Steroid use, Opioid use, Corticosteroid use, antiseizure (anticonvulsants) or antifungal medications?**

Yes

Please specify:

Please list the other medications that you are currently taking, including the reason, dosage, and frequency.**

Example: Ciprelax, 20mg once a day for anxiety - or "none"

ALLERGY

Are you allergic to lidocaine (freezing agent)?**

Yes

Type:

Are you allergic to tetracaine (freezing agent)?**

Yes

Type:

FAMILY HISTORY

Please select all that apply:**

Prostate cancer

Benign prostate hyperplasia (BPH)

Hypogonadism (low testosterone)

Erectile dysfunction

None of the above

SEXUAL HEALTH CONCERNS

Please select all that apply:**

Erectile Dysfunction

Peyronie's disease

Premature Ejaculation

Low Testosterone

Penis Enlargement

Delayed Ejaculation

Other

Please specify**

HISTORY OF SEXUAL FUNCTION

Have you noticed a decline in your sexual performance?**

Yes

For how long?*

If you have been suffering from erectile dysfunction (ED) how long has it been?**

Have you ever been able to achieve erection with self-stimulation (masturbation) without any pills?**

Yes

Do you wake up with morning erections?**

Yes

How often in a month?**

How long does it last in the morning?**

Do you have any issues with ejaculation?**

Yes

Do you have any issues with orgasm?**

Yes

Do you experience erectile dysfunction in certain positions such as lying down, upon getting up, or seated?**

Yes

Please specify:

What is your idea about the cause of your erectile dysfunction?**

In the last 4 weeks were you using pills, injections, or supplements (Viagra, Cialis, Levitra, etc)?**

Yes

Erection Hardness Score - Please respond to describe your erections when you are not taking pills or other erection aids.

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

IIEF Questionnaire - Please respond to describe your sexual performance over the past 6 months.

1. How do you rate your confidence that you could get and keep an erection?*

2. When you had erections with sexual stimulation, how often were your erections hard enough for penetration?*

Almost never/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/always

3. During sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner?*

Almost never/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/always

4. During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?*

5. When you attempted sexual intercourse, how often was it satisfactory for you?*

Almost never/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/always

How often were you able to get an erection during sexual activity?**

When you had erections with sexual stimulation, how often were your erections hard enough for penetration?**

When you attempted intercourse, how often were you able to penetrate (enter) your partner?**

During sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner?**

During sexual intercourse, 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?**

RISK FACTORS FOR ERECTILE DYSFUNCTION

Do you ride a bicycle regularly?**

Yes

Have you injured your spinal cord?**

Yes

What year?

Have you had your prostate removed for cancer?**

Yes

What year?

Have you undergone radiation therapy for prostate cancer?**

Yes

What year?

Have you had prostate surgery (TURP) for benign prostatic growth?**

Yes

What year?

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?**

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?**

Yes

How bothered are you with having intercourse les often?*

PENTOXIFYLLINE SCREENER

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

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)?**

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

Do you take medication for high blood pressure?**

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)?**

Yes

Please specify**

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

Yes

Please specify**

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

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?**

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

In the middle of the shaft

At the base of the penis

Do you have penile pain with erections?**

Yes

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

Yes

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

Yes

Do you have an indentation on your penis?**

Yes

Do you experience penile shortening when erect?*

Yes

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?**

Enter "N/A" if not applicable.

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*

SEXUAL PARTNER

What is your sexual orientation?**

Heterosexual

Homosexual

Bisexual

Prefer not to answer

Do you currently have a partner?**

Yes

Please specify how long you have been together?**

Are you able to have intercourse?**

Yes

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

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

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

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

Not at all	Mildly impaired	Moderately impaired	Severely impaired

PREMATURE EJACULATION EVALUATION

How difficult is it for you to delay ejaculation? What is the time between penetration and ejaculation?**

Do you ejaculate before you want to?**

Do you ejaculate with very little stimulation?**

Do you feel frustrated because of ejaculating before you want to?**

How concerned are you that your time to ejaculate leaves your partner unfulfilled?**

How long does it usually take for you to ejaculate during intercourse?**

Less than 1 minute	Between 1 and 3 minutes	Beyond 3 minutes

Have you been having premature ejaculation since your first experience of sexual intercourse and with every partner?**

Yes

Please explain :

What type of treatment(s) have you had in the past for premature ejaculation? Please be specific regarding the type of treatment**

Include any medication and dosages and their effectiveness for you, the year of the treatment and the treating physician(s). Enter "none" if none

TESTOSTERONE DEFICIENCY

Have you experienced a decrease in your sex drive (libido)?**

Yes

Do you lack energy or feel weak?**

Yes

Has your strength or endurance decreased?**

Yes

Have you lost height?**

Yes

Have you noticed yourself enjoying life less?**

Yes

Are you frequently sad or particularly irritable?**

Yes

Are your erections less strong?**

Yes

Have you noticed a recent deterioration in your athletic ability?**

Yes

Do you find yourself falling asleep after dinner?**

Yes

Has there been a recent deterioration in your work performance?**

Yes

PREVIOUS EVALUATION

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

Yes

Have you ever received a penile injection?**

Yes

Did it produce a full erection?

Yes

Have you undergone a penile blood flow study?**

Yes

What was the result?

Normal

Abnormal

Have you undergone testing of erections during sleep?**

Yes

What was the result?

Normal

Abnormal

PREVIOUS TREATMENT AND RESPONSES

Have you ever tried PDE5-inhibitors (Viagra, Levitra or Cialis)?**

Yes

How was your response to PDE5-inhibitors?

I am able to obtain and maintain erection all the time with PDE5-inhibitors.

I inconsistently respond to PDE5-inhibitors

I do not respond to PDE5-inhibitors at all

Did PDE5-inhibitors work to your satisfaction?

Yes

Do you experience any side effects related to PDE5-inhibitors (Viagra, Levitra or Cialis)?

Yes

Please specify the side effects:

Do you like taking these pills?

Yes

Have you tried MUSE therapy (intraurethral prostaglandin)?**

Yes

Did the MUSE work for you?

Yes

Do you like using the MUSE?

Yes

Have you tried Caverject (Intracavernosal injectable prostaglandin)?**

Yes

Did the Caverject work for you?**

Yes

Do you like using the Caverject?

Yes

Have you tried the vacuum erection device (VED)?**

Yes

Did the VED work for you?

Yes

Do you like the VED?

Yes

Have you ever had penile prosthesis (implant) surgery?**

Yes

What year?

Are you interested in the option of penile prosthesis surgery for your erectile dysfunction?

Yes

CLINIC POLICY AND GENERAL CONSENT

At Buenafe Clinic we are dedicated in providing quality medical care to our patients. By signing this clinic policy and general consent, you acknowledge that you understand and agree to the following:

Confidentiality and Privacy

We understand the importance of confidentiality for our patients. Buenafe Clinic is in compliance with all applicable laws to maintain client privacy and confidentiality. All communication between the client, the physician, therapists, and employees at Buenafe Clinic will remain confidential. If you would like a detailed copy of our privacy policy, we will provide it upon request.

Privacy Officer: Abbie R.N. Email: drjay@buenafeclinic.com Phone: 204-697-9013

Late Cancellations and No Shows

Out of courtesy to the doctor and other patients, please call Buenafe Clinic two business days in advance if you are unable to make your scheduled appointment. Buenafe Clinic will charge a cancellation fee of $150.00 CAD for any no shows or late cancellations and will be charged to the credit card on file. By signing the clinic policy and general consent, you provide full consent to charge the credit card on file.

Clinic Code of Conduct

We will not tolerate any rude or aggressive behavior towards our staff. Sexual harassment or sexual comments to our staff and guests of Buenafe Clinic will not be tolerated. Any mistreatment or comments will result in immediate termination of the doctor-patient relationship and future treatments will be cancelled. Please understand there must be a mutually respected doctor-patient relationship to provide quality healthcare. If for any reason, the relationship is in question, the patient will be dismissed from the clinic.

Scope of Care

I understand that Buenafe Clinic Men’s Sexual Health Program (MSH) is a private clinic, and that our doctors are not enrolled in the the provincial medical plan. Buenafe Clinic offers multiple treatment options including but not limited to: Sex therapy, pharmacotherapy, and new innovative treatment modalities such as low intensity Shockwave Therapy and Platelet Rich Plasma Therapy for premature ejaculation and/or erectile dysfunction. We do NOT give prescription refills for medication that we have not prescribed. We do NOT refill any narcotics, sleeping pills, benzodiazepines, or stimulants.

I agree that I am solely responsible to consult with my family physician (GP) or a primary care provider if I would like to complete any analyses including but not limited to comprehensive blood test analysis to determine any disease processes that possibly contribute to erectile dysfunction and/or other sexual performance issues.

Health Information, Research and General Media Consent

Buenafe Clinic and Pollock Clinics is a leading training facility. Dr Neil Pollock is a Clinical Instructor at The University of British Columbia Faculty of Medicine and has been a guest lecturer and surgical educator at hospitals all over the world. Our clinical programs provide leading technologies in Men`s Sexual Health. Below you can consent to have your health information used in our education seminars and or research papers and studies.

Please review and check below.

I consent to having medical students observe my treatment and therapies.

I consent to photographs and other audio-visual and graphic material before, during and after the course of treatment to be used for medical, marketing and educational purposes. Although the photography or accompanying material will not contain my name or any other identifying information, I am aware that I may or may not be identified by the photos.

I consent to my photos and or health information used for program development and studies.

Consent for Electronic Communications

I understand that according to the privacy act Personal Information Act (PIPA) and Personal Information & Electronic Documentation Act (PIPEDA) that email is not a preferred method of communication. Some patients prefer email as the main method of communications. This can include updates, labs, photography, personal information and appointments. Please consent below.

I consent to communications through phone.

I consent to communications through text.

I consent to communications through email.

Validity and Length of Treatment Consent*

I fully understand the information received above and provide full informed consent for my appointment. The Clinic Policy and General Consent is valid for one year from the date of signature as outlined below. If you agree to the above information, please sign below

I have read and understand all information presented to me before signing this consent form. I have been given an opportunity to have all my questions answered to my satisfaction. I agree to the terms of this agreement.

Signature*

Date*

Men's Sexual Health Registration

PATIENT INFORMATION

FAMILY DOCTOR INFORMATION

PERSONAL HISTORY

MEDICAL & SURGICAL HISTORY

MEDICATIONS

ALLERGY

FAMILY HISTORY

SEXUAL HEALTH CONCERNS

HISTORY OF SEXUAL FUNCTION

Erection Hardness Score - Please respond to describe your erections when you are not taking pills or other erection aids.

IIEF Questionnaire - Please respond to describe your sexual performance over the past 6 months.

RISK FACTORS FOR ERECTILE DYSFUNCTION

PEYRONIE’S DISEASE BOTHER DOMAIN QUESTIONNAIRE

PENTOXIFYLLINE SCREENER

PENILE CURVATURE INTAKE FORM

HISTORY OF ERECTILE FUNCTION

SEXUAL PARTNER

IMPACT

PREMATURE EJACULATION EVALUATION

TESTOSTERONE DEFICIENCY

PREVIOUS EVALUATION

PREVIOUS TREATMENT AND RESPONSES

CLINIC POLICY AND GENERAL CONSENT

Consent for Electronic Communications

Buenafe Clinic

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