PLEASE CIRCLE THE MOST ACCURATE ANSWER OR FILL IN THE BLANKS |
| I. History |
| 1. When did you first notice the presence of Peyronie's Disease?______________________ |
| 2. What was your first symptom? (Pain) (Lump) (Curvature or bend) |
| 3. Did your penile deformity occur: (Suddenly) (Gradually) |
| 4. Do you recall (pain), (injury) or (bending) of your penis during intercourse before developing Peyronie's Disease? ( ) No ( ) Yes (Please describe:______________________) |
| 5. Do you recall any other injury to your penis? ( ) No ( ) Yes (When did this occur and what was the nature of your injury?______________________________________________________) |
6. Have you been treated for Peyronie's Disease prior to this visit? ( ) No ( ) Yes (Circle the treatments you have received): (Vitamin E) (Potaba) (Colchicine) (Tamoxifen)
(Injections: Verapamil, Interferon, steroids) (Anti-inflammatory medication)
(Other):_____________________________________________________________________
Did you note any benefit from this therapy? ( ) No ( ) Yes: What?_____________________ |
| 7. Are you currently undergoing treatment for Peyronie's Disease? ( ) No ( ) Yes (What treatment are you currently receiving?)________________________________________________ |
8. Do you or a family member have a history of: (Dupuytren's contracture) (Lederhose disease) (any unusual scarring disorders) ( ) No ( ) Yes (Please further explain if you or a
family member are affected):______________________________________________________ |
9. Has your penile curvature worsened over time? ( ) No ( ) Yes: Is it stable now? ______
For how long? ________________________________________________________________ |
10. Would you describe your penile curvature as: ( ) Up ( ) Down ( ) Left ( ) Right
Can you estimate the degree of curve? (Right angle is 90°, straight is 0°)___________________ |
| 11. Have you noticed any shrinking or loss of length of your penis? ( ) No ( ) Yes (Estimate how much in inches) _____________________________________________________________ |
12. Have you noticed any other deformity? ( ) No ( ) Yes: (Circle all that apply)
(Hinge effect at head) (Hinge effect at base)
(Narrowing of shaft): Left Right All around like hourglass: where? - base mid end of shaft
(Softening of penis beyond lump/scar or curve) |
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THE FOLLOWING QUESTIONS ASK YOU TO GRADE THE QUALITY OF YOUR ERECTIONS - PLEASE CIRCLE THE NUMBER THAT BEST DESCRIBES THE QUALITY OF YOUR ERECTIONS |
| As a guide, anything less than a 7 cannot be pushed into the vagina. A 10 is a fully "rock-hard" erection. Please answer this question regarding your penile rigidity while imagining that your penis has no curvature. |
| No Erections (0) (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) Full Erections |
13. Prior to developing Peyronie's Disease, would you grade your erection as:
GRADE: (0) (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) |
| 14. Do you have any difficulty in maintaining your erection after penetration? ( ) No ( ) Yes |
15. Do you currently have an erection in the morning before you urinate?
( ) No ( ) Yes (How often?)______________________________________________________
GRADE: (0) (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) |
16. Do you currently ever awaken at night and notice an erection?
( ) No ( ) Yes (How often?)______________________________________________________
GRADE: (0) (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) |
17. At the present time, are you capable of having sexual intercourse?
( ) No ( ) Yes (How often?)______________________________________________________ |
| 18. What is your sexual partner preference? (Women) (Men) (Both) |
| 19. Currently, do you experience pain in your penis during sexual activity? ( ) No ( ) Yes |
| 20. Have you experienced pain in your penis at any time while you've had Peyronie's Disease? ( ) No ( ) Yes (At first but now gone) (From start till now) |
| 21. Does your partner experience pain during sexual intercourse due to the penile deformity? ( ) No ( ) Yes |
22. Do you have difficulty with penetration due to (circle all that apply):
(Curvature) (Hinge effect) (Lack of firmness) |
| 23. Do you feel the presence of Peyronie's Disease has affected your emotional status? ( ) No ( ) Yes |
| 24. Has the presence of Peyronie's Disease affected your relationship with your sexual partner? ( ) No ( ) Yes |
| 25. Do you consider your sexual desire/libido: (Normal) (Low) (High) |
| 26. Have you noticed any change in the sensation of your penis since developing Peyronie's Disease? ( ) No ( ) Yes: (Decreased sensation) (Numbness) (Painful sensation) |
27. Are you able to ejaculate? ( ) No ( ) Yes (By what method - circle all that apply)
(Intercourse) (Masturbation) (Oral sex) |
28. Are you troubled by rapid ejaculation? ( ) No ( ) Yes: (Recently-only occasionally)
(Consistently throughout lifetime) (Occasionally throughout lifetime) (Recently-almost always) |
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| 29. Do you currently smoke tobacco? ( ) No ( ) Yes: (Cigarettes) (Cigars) (Pipes) How much and long? (Per day/week/month _____________) (For _________ years/months) |
30. Have you smoked tobacco in the past? ( ) No ( ) Yes: (How much: _______________)
(For how long: ______________________) (When did you quit: ______________________) |
31. Do you currently consume alcoholic beverages? ( ) No ( ) Yes: (Wine) (Beer) (Other)
How much: (Rarely) ( _____drinks per day) ( _____drinks per week) ( ___drinks per month) |
32. Have you in the past consumed alcoholic beverages? ( ) No ( ) Yes: (Wine) (Beer)
(Other) How much: (Rarely) ( _____drinks per day) ( _____drinks per week) ( ___drinks per month) When did you stop: ________________________ (Have a history of alcoholism) |
33. Are you presently taking medication prescribed by any doctor? ( ) No ( ) Yes (Please
list all): _____________________________________________________________________ |
34. Do you have a history of any of the following (even if under control now with medicine)? (circle all that apply): (Diabetes) (High blood pressure) (Elevated cholesterol)
(Coronary heart disease) (Severe straddle injury) (Back trauma/surgery)
(any other vascular disease; if yes, what: ________________________________________)
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