Intake Form - GAINSWave Boca Raton

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Patient Profile Sheet

PLEASE PRINT CLEARLY

Patient Information

Date *

Full Name *

Middle Name

Last Name

Date of Birth *

Address *

Address2

City

State

Zip Code

Phone *

Employer *

Are you currently taking any medications? *

Email *

Employment Status *

Emergency Contact Information

eciname

ecilastname

eciAddress

eciAddress2

eciCity

eciState

eciZip Code

eciPhone

Relationship to patient

Parent Significant Other Sibling Child Friend Other

Notes

Medical History Questionnaire: Men's Health

Erectyle Dysfucntion Questionnaire

When did it start?

Have you tried:

VIAGRA CIALIS LEVITRA EDIX VED/PUMP THERAPY TESTOSTERONE

How did it work?

Did you experience side effects?

How firm are your natural erections?

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

How frequently do you have morning erections?

Daily Weekly Monthly Rarely Never

Medical Conditions

Please List Current Medications/Supplements

Surgical History

Social History

Single Dating Married Divorced Widowed

Medical History Questionnaire

Arthritis

Yes No

Diabetes

Yes No

High Blood Pressure

Yes No

Heart Attack

Yes No

Heart Disease

Yes No

Multiple Sclerosis

Yes No

Epilepsy

Yes No

Hepatitis

Yes No

Bowel Problems

Yes No

Cancer

Yes No

Blood Transfusion

Yes No

Tuberculosis

Yes No

Uro-Genital Problems

Yes No

Sickle Cell Disease (Anemia)

Yes No

Sickle Cell Disease Trait Only

Yes No

Peyronie's Disease

Yes No

Fabry's Disease

Yes No

Headaches

Yes No

High Cholesterol

Yes No

Blocked Artery

Yes No

Stroke

Yes No

Parkinson's Disease

Yes No

Liver Disease

Yes No

Kidney Disease

Yes No

Prostate Problems

Yes No

Acute Pain or Swelling

Yes No

HIV Infection / Aids

Yes No

Major Depression

Yes No

Bleeding Disorder

Yes No

Skin Problems

Yes No

Sexually Transmitted

Yes No

Herpes

Yes No

Malaria

Yes No

Leukemia

Yes No

Do you smoke?

Yes No

How many packs per day? *

Do you consume alcoholic beverages?

Yes No

Do you currently use drugs such as marijuana, cocaine, or other similar or illegal drugs?

Yes No

IIEF/SHIM International Index of Erectile Function

How do you rate your confidence that you could achieve and keep an erection? *

1 2 3 4 5 1-Very low 2-low 3- Moderate 4- High 5- Very High

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

1 2 3 4 5 1- Almost never/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

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

1 2 3 4 5

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

1 2 3 4 5 1- Extremely difficult 2- Very difficult 3- Difficult 4- Slightly Difficult 5- Not difficult

When you attempted sexual intercourse, how often was it satifactory for you? *

1 2 3 4 5 1- Almost never/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

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