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Silver Spring Medical Group
6915 Laurel Bowie Rd. Suite 101 Bowie, Maryland 20715 Telephone: (301) 262-1087 Fax: (240) 436-2850
New Patient Information Form
Please fill this form in to help us better take care of you.
Name
*
First Name
Last Name
DOB
*
-
Month
-
Day
Year
Date Picker Icon
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Pharmacy name and Address
NAME OF PHARMACY
Street
City
State / Province
Postal / Zip Code
Patient Marital Status
*
Married
Single
Divorced
Separated
Widowed
Decline to Respond
Other
Race
*
White
African-American
Hispanic
Decline to Respond
Other
Occupation:
Do you drink alcohol?
*
Yes
No
APPROXIMATE DURATION OF PROBLEM IN YEARS:
Year/Years
ONSET OF THE PROBLEM WAS
*
Gradual
Sudden
If sudden, was it related in onset to: (Choose One)
*
Surgery
New medication
Life event
Penile injury
Hypertension/high blood pressure
Anti-hypertensive medication
Work-related
Stress
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? (Choose One)
*
Did not engage in any sexual activity
Almost never
A few times (much less than half the time)
sometimes (about half the time)
most times (much more than half the time)
almost always/always
Over the past 30 days, when you had erections, how often were the erections firm enough to have sexual relations? (Choose One)
*
Did not engage in any sexual activity
Almost never
A few times (much less than half the time)
sometimes (about half the time)
most times (much more than half the time)
almost always/always
When you attempted sexual intercourse, how often were you able to penetrate (enter) your partner? (Choose One)
*
Did not attempt intercourse
Almost never
A few times (much less than half the time)
sometimes (about half the time)
most times (much more than half the time)
almost always/always
When you attempted sexual intercourse, how often was your erection satisfactory in your opinion? (Choose One)
*
Did not attempt intercourse
Almost never/never
A few times (much less than half the time)
sometimes (about half the time)
most times (much more than half the time)
almost always/always
During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse? (Choose One)
*
Unable to attempt intercourse
extremely difficult
very difficult
difficult
slightly difficult
not difficult
How would you rate your level of sexual desire? (Choose One)
*
very low/none at all
low
moderate
high
very high
What is the quality of the best erection you have experienced during the night or upon awakening in the morning during the past month? (Choose One)
*
none at all
partial (less than half)
partial (better than half)
full erection
What is the rigidity of your penis upon achieving orgasm? (Choose One)
*
unable to achieve orgasm
no erection at all
partial (equal to or less than half erect)
partial (better than half erect)
full erection
Do you have an active sexual partner at this time? (Wife, Girlfriend, Other, None):
Can you achieve an orgasm? (Choose One)
*
Yes
No
Do you have morning erections? (Choose One)
*
Yes
No
Can you ejaculate normally? (Choose One)
*
Yes
No
Do you have premature ejaculation? (Choose One)
*
Yes
No
Do you think there is an emotional cause? (Choose One)
*
Yes
No
Do you experience any pain with erections? (Choose One)
*
Yes
No
Have you noted any change in the bend during the past six months? (Choose One)
*
Yes
No
PREVIOUS EVALUATION
Have you had your testosterone level measured? (Choose One)
*
Yes
No
If so, what were the results? (Choose One)
*
Normal
Abnormal
Don't Know
Have you ever received a penile injection? (Choose One)
*
Yes
No
If so, did it produce a full erection? (Choose One)
*
Yes
No
Have you undergone a penile blood flow study? (Choose One)
*
Yes
No
If so, what was the result? (Choose One)
*
Normal
Abnormal
Don't Know
Have you undergone testing of erections during sleep? (Choose One)
*
Yes
No
If so, what was the result? (Choose One)
*
Normal
Abnormal
Don't Know
Back
Next
PREVIOUS TREATMENT
Have you tried Viagra, Levitra or Cialis? (Choose One)
*
Yes
No
Did Viagra work to your satisfaction? (Choose One)
*
Yes
No
Have you tried MUSE (Medicated Urethral System for Erections)? (Choose One)
*
Yes
No
Has not tried
Did MUSE produce a satisfactory erection? (Choose One)
*
Yes
No
Has not tried
Do you like using MUSE? (Choose One)
*
Yes
No
Have you tried injection therapy? (Choose One)
*
Yes
No
Did the injections produce a satisfactory erection? (Choose One)
*
Yes
No
Do you like doing injections? (Choose One)
*
Yes
No
Have you tried the vacuum device? (Choose One)
*
Yes
No
If so, did it work? (Choose One)
*
Yes
No
Has not tried
Have you tried any other treatments? (Choose One)
*
Yes
No
If so, what was this treatment?
RISK FACTORS FOR ERECTILE DYSFUNCTION
Yes
No
Have you ever injured your penis?
Has your penis ever been forcibly bent while erect?
Have you had a straddle injury?
Do you ride a bicycle regularly?
Have you ever smoked cigarettes regularly?
If so, do you currently smoke?
Have you ever had problems with excessive alcohol drinking?
Have you injured your spinal cord?
Have you had your prostate removed for cancer?
Have you undergone radiation therapy for prostate cancer?
Have you had prostate surgery (TURP) for benign prostatic growth?
How many children do you have? (Number)
PAST MEDICAL HISTORY
Yes
No
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?
Do you take aspirin regularly?
Are you being treated for diabetes mellitus?
Yes
No
If so, which treatment method are you using to control your sugar?
*
Diet
Pills
Insulin
Other medical illnesses:
Past Surgeries:
List medications:
List any medications that you are allergic to:
FAMILY HISTORY: Do you have a family history of:
Yes
No
High blood pressure
Heart disease
Peyronie’s disease
Diabetes
Prostate cancer
Cancer
Submit
Should be Empty: