Sexual History
Do you have problems getting an erection?
Do you have problems maintaining an erection?
Has the firmness of your erection decreased?
Does your erection last as long as your partner would like?
Are the problems you are experiencing affecting your relationship?
Do you ejaculate or climax too soon?
Are you able to get another erection soon after you ejaculate?
Do you have any problem with ejaculating or climaxing?
Do you now, or have you in the past, had a significant curvature of the penis when you have a full erection?
Please List Any Procedures Along with the Year and the Physician:
Are you allergic to any medications?
If yes, please list medications in the comments area below.
Have you or a family member had any of the following:
Diabetes
If yes, was it you or a family member, or both? (Type in family relationship.)
High Blood Pressure
If yes, was it you or a family member, or both? (Type in family relationship.)
Poor Blood Flow
If yes, was it you or a family member, or both? (Type in family relationship.)
Smoking
If yes, was it you or a family member, or both? (Type in family relationship.)
Enlarged Prostate
If yes, was it you or a family member, or both? (Type in family relationship.)
High Cholesterol
If yes, was it you or a family member, or both? (Type in family relationship.)
Cancer
If yes, was it you or a family member, or both? (Type in family relationship.)
Hepatitis
If yes, was it you or a family member, or both? (Type in family relationship.)
Sickle Cell Anemia
If yes, was it you or a family member, or both? (Type in family relationship.)
Drink Alcoholic Beverages
If yes, was it you or a family member, or both? (Type in family relationship.)
Heart Disease
If yes, was it you or a family member, or both? (Type in family relationship.)
Stroke
If yes, was it you or a family member, or both? (Type in family relationship.)
Chest Pains
If yes, was it you or a family member, or both? (Type in family relationship.)
Shortness of Breath
If yes, was it you or a family member, or both? (Type in family relationship.)
Spinal Cord Injury
If yes, was it you or a family member, or both? (Type in family relationship.)
Back Injury
If yes, was it you or a family member, or both? (Type in family relationship.)
Pelvic Injury
If yes, was it you or a family member, or both? (Type in family relationship.)
What else should the Doctor know?
Patient Instructions
Sexual health is an important part of an individual’s overall physical and emotional well-being. Erectile dysfunction, formerly referred to as impotence, is the one type of very common medical condition affecting sexual health. Fortunately, there are many different treatment options for erectile dysfunction. This questionnaire is designed to help your doctor identify the extent of your dysfunction.
Each question has several possible responses. Click the number of the response that best describes your own situation. Please be sure you select one and only one for each question.
How do you rate your confidence that you could get and keep an erection?
When you had erections with sexual stimulation, how often were your erections hard enough for penetration (entering 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?
During sexual intercourse, how often was it satisfactory for you?
Over the last month or so, how often have you had a sensation of not emptying your bladder completely after you finished urinating?
During the last month or so, how often have you had to urinate again less than two hours after you finished urinating?
During the last month or so, how often have you stopped and started again several times when you urinated?
During the last month or so, how often have you found it difficult to postpone urination?
During the last month or so, how often have you had a weak urinary stream?
During the last month or so, how often have you had to push or strain to begin urination?
During the last month, how many times did you most typically get up to urinate from the time you went to bed at night until the time you got up in the morning?
Do you have a decrease in libido (sex drive)?
Do you have a lack of energy?
Do you have a decrease in strength and/or endurance?
Have you noticed a decreased "enjoyment of life"?
Are you sad and/or grumpy?
Are your erections less strong?
Have you noticed a recent deterioration in your ability to play sports?
Are you falling asleep after dinner?
Has there been a recent deterioration in your work performance?
If you were to spend the rest of your life with your erectile dysfunction the way it is now, how would you feel about that?
PD LABS, INC.
Notice of Privacy Practices
HIPAA
Consent for Treatment
I hereby give consent and authorize such medical treatment as may be ordered by the physician(s) associated with PD Labs.
I understand I may revoke this consent in writing at any time. I understand I may discuss any of the matters covered by this Consent for Treatment, HIPAA, and Notice of Privacy Practices by asking for the PD Labs Medical Privacy Officer.
PD Labs is committed to protecting the privacy of patients. As required by law, we treat all health information confidentially. PD Labs has developed a Privacy Compliance Program to ensure the privacy and confidentiality of your health information. This Program was designed to recognize and enforce the guidelines and the laws of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
We are required by law to protect your health information. We offer this Notice about our privacy practices, our legal duties and your rights concerning your health information. Uses and disclosures of your health information will be made only with your written permission. You can revoke that permission in writing.
For more information or if you have questions, you may contact our Medical Privacy Officer. If you believe your privacy rights have been violated, you can file a complaint with the Secretary of the U.S. Department of Health and Human Services or directly with PD Labs by contacting the Medical Privacy Officer.
PD Labs reserves the right to change the privacy practices and the terms of this Notice at any time, but only as permitted by law. We reserve the right to make those changes required by law, effective for all health information. Our privacy practices will remain in effect until we change this Notice. If significant changes are made to our privacy practices, we will change this Notice and make the new Notice available upon request.
