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Peyronie's Patient Questionaire
Patient History
Current/past medical problems
Yes No Describe
Allergy
Arthritis
Cancer
Diabetes
Heart Disease
Hypertension
Liver Disease
Hepatitis
(Indicate type A or B if known)
Skin Disorder
Scieroderma
Earlobe Thickening
Hearing Loss
Surgery
Trauma
Venereal Disease
(Heipes, Gonorrhea, Syphilis)
HIV Infection
(AIDS)
Dupuytren's
Contracture
(Scar in the hand such as President Reagan
had operated on before he left office)
Ledderhose
Disease
(Scar on sole of foot similar to
Dupuytren's Contracture)
List medications you are or have been taking
within the year of peyronie's onset:
Medication Dosage
Peyronie's disease may be family- related.
List family members who have had peyronie's disease
or any of the conditions in the list above:
Family Member Disease
Do you smoke? Yes No
If yes, what and how much?_________________________
Do you drink alcohol? Yes No
If yes, what and how much?________________________
Do you drink coffee containing caffeine? Yes No
If yes, how much per day?
Do you drink soft drinks containing caffeine? Yes No
If yes, how much per day?
Are you: heterosexual homosexual
Have you ever been involved in an accident in
which your penis was hurt? Yes No
If yes, explain:
Do you recall any trauma to your erect penis during
intercourse (such as acute pain or bending)? please indicate
Yes No
Date and describe:______________________________
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Patient History
Current/past medical problems
Yes No Describe
Allergy
Arthritis
Cancer
Diabetes
Heart Disease
Hypertension
Liver Disease
Hepatitis
(Indicate type A or B if known)
Skin Disorder
Scieroderma
Earlobe Thickening
Hearing Loss
Surgery
Trauma
Venereal Disease
(Heipes, Gonorrhea, Syphilis)
HIV Infection
(AIDS)
Dupuytren's
Contracture
(Scar in the hand such as President Reagan
had operated on before he left office)
Ledderhose
Disease
(Scar on sole of foot similar to
Dupuytren's Contracture)
List medications you are or have been taking
within the year of peyronie's onset:
Medication Dosage
Peyronie's disease may be family- related.
List family members who have had peyronie's disease
or any of the conditions in the list above:
Family Member Disease
Do you smoke? Yes No
If yes, what and how much?_________________________
Do you drink alcohol? Yes No
If yes, what and how much?________________________
Do you drink coffee containing caffeine? Yes No
If yes, how much per day?
Do you drink soft drinks containing caffeine? Yes No
If yes, how much per day?
Are you: heterosexual homosexual
Have you ever been involved in an accident in
which your penis was hurt? Yes No
If yes, explain:
Do you recall any trauma to your erect penis during
intercourse (such as acute pain or bending)? please indicate
Yes No
Date and describe:______________________________
click for next page