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                                       Peyronie's Patient Questionaire


Has swelling or bruising of the penis ever occurred
after sexual intercourse?                  Yes  No
Please indicate date and describe:________________________


      Sexual History
Sexual history before the onset of peyronie's disease:
Frequency of intercourse:____________________________
State of erection: ____________________________________
Straight
                         Describe
Bent up
Down
Left
Right

Firm   Moderate       Soft
Describe:

Persistence of erection:
Good    Moderate       Poor
Describe:

Night - time erections:                    Yes   No
Describe: ___________


Pain: When not erect?                      Yes No
Describe: ________________________________________


When erect?                           Yes   No
Describe: _____________________________

Did you have problems attaining or maintaining
Erections?                                 Yes   No
If yes, were they during:

Making love before intercourse?            Yes   No
Attempts to begin intercourse?             Yes   No
Intercourse?                               Yes   No
Describe:

If you had other problems relating to Intercourse,
were they related to:
Lack of desire                             Yes  No
Partner losing interest               Yes  No

Have you had a problem with orgasm?     Yes  No
Was it:
Too Rapid                                 Yes  No
Too Slow                                   Yes  No

Positions during intercourse - Frequency
Man on top mostly                 Some   Infrequently
Woman on top mostly           Some   Infrequently
Other:


      Sexual History After Onset
Sexual history after the onset of peyronies disease:
Frequency of intercourse:_________________________
State of erection:____________________________________
Straight
                         Describe
Bent up
Down
Left
Right

Firm    Moderate  Soft
Describe: _______________


Persistence of erection:
Good   Moderate  Poor
Describe:

Night-time erections:                      Yes  No
Describe:

Peyronies Patient Questionaire


Pain: When not erect?                          Yes   No
Describe: _________________________________________

When erect?                              Yes   No
Describe: _________________________ _______________________

Did you have problems attaining or maintaining
Erections?                                     Yes   No
If yes, were they during: _____________________________

Making love before intercourse?                Yes   No
Attempts to begin intercourse?                 Yes   No
Intercourse?                                   Yes   No
Describe:

If you had other problems relating to Intercourse,
were they related to:
Lack of desire                                Yes  No
Partner losing interest                 Yes  No

Have you had a problem with orgasm?        Yes  No
Was it:
Too Rapid                                    Yes  No
Too Slow                                      Yes  No

Positions during intercourse - Frequency
Man on top mostly                  Some     Infrequently
Woman on top mostly            Some     Infrequently
Other:

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