Medical History Form | Hormone Replacement Program for Men and Women

Patient Info

Please fill out the medical history form below. For new patients, the medical history form is required to be submitted before your order can ship out.

Please enter the date

Please enter your name (last first middle).

Please enter your birthdate

Please enter your occupation

Please enter your email address.

Please enter your Referring Physician Name.

Please enter your Referring Physician Specialty.

Please enter your Primary Care Physician Name.

Patient history

Please enter your age.

Please enter Approximate Duration of problem in years.

ONSET OF THE PROBLEM WAS:

If sudden, was it related in onset to:

Present Sexual Function:

Over the past 30 days, how often have you had partial or full erections when you were sexually stimulated in any way?

Over the past 30 days, when you had erections, how often were the erections firm enough to have sexual relations?

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

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

When you attempted sexual intercourse, how often was your erection satisfactory in your opinion?

How would you rate your level of sexual desire?

What is the quality of the best erection you have experienced during the night or upon awakening in the morning during the past month?

What is the rigidity of your penis upon achieving orgasm?

Do you have an active sexual partner at this time? (Wife, Girlfriend, Other, None):

Can you achieve an orgasm?

Can you ejaculate normally?

Do you have premature ejaculation?

Do you think there is an emotional cause?

Do you experience any pain with erections?

Are or were your erections abnormally bent?

If so, Which direction is it bent? (Up, Down, Left, Right):

How many degrees is the bend?

Have you noted any change in the bend during the past six months?

Previous Evaluation:

Have you had your testosterone level measured?

If so, what were the results? (Normal, Abnormal, Don’t know):

Have you ever received a penile injection?

If so, did it produce a full erection?

Have you undergone a penile blood flow study?

If so, What was the result? (Normal, Abnormal, Do not know):

Have you undergone testing of erections during sleep?

If so, What was the result? (Normal, Abnormal, Do not know):

Previous Treatment:

Have you tried Viagra, Levitra or Cialis?

Did Viagra work to your satisfaction?

Have you tried MUSE?

Did MUSE produce a satisfactory erection?

Do you like using MUSE?

Have you tried injection therapy?

Did the injections produce a satisfactory erection?

Do you like doing injections?

Have you tried the vacuum device?

Did it work?

Do you like the vacuum device?

Have you tried any other treatments?

What was this treatment?

Risk Factors For Erectile Dysfunction:

Past Medical History:

Are you being treated for diabetes mellitus?

If so, which treatment method are you using to control your sugar?

Are you being treated for high blood pressure?

Are you being treated for elevated blood cholesterol level?

Do you have heart disease?

Have you ever had a stroke?

Have you been told that you have hardening of the arteries?

Are you or have you been treated for depression?

Other medical illnesses:

Past Surgery:

List medications:

Do you take aspirin regularly?

List any medications that you are allergic to:

Family History:

Do you have a family history of:

High blood pressure:

Diabetes:

Heart disease:

Prostate cancer:

Peyronie’s disease:

Cancer

Medical History

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