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Erectile Dysfunction
GAINSWave
Testosterone
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Erectile Dysfunction
GAINSWave
Testosterone
Our Team
Media
Contact Us
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Patient Profile Sheet
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Patient Information
Date
*
Full Name
*
Middle Name
Last Name
Date of Birth
*
Address
*
Address2
City
State
- Select Province/State -
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
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====================
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Zip Code
Phone
*
Employer
*
Are you currently taking any medications?
*
Yes
No
Email
*
Employment Status
*
Emergency Contact Information
eciname
ecilastname
eciAddress
eciAddress2
eciCity
eciState
- Select Province/State -
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Nova Scotia
Northwest Territories
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
====================
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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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