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A VERY HANDY GUIDE
When you developed Peyronies Disease you were probably in a state of
shock and had no idea about was going on. During your visit to the urologist,
it is certain that you did not know what questions to ask in order to assist him
in performing a thorough examination. The probability is that he did not
perform an appropriate and comprehensive examination. For example, did
you know that if you have Peyronies you are at an increased risk for two
additional, related impairments; Dupuytren’s Contracture and Ledderhose
Disease? Who ever heard of these medical conditions before and did your
physician examine you for these conditions? The Devine Center for
Genitourinary Reconstruction at Sentara Norfolk General Hospital has
produced a Peyronie’s Patient Questionnaire.
It is very through and I strongly suggest that you print it out and then
complete it. It will help you organize the information about your Peyronies
and assist you in guiding your physician so you will get the most out of your
office visit. This is definitely worthwhile.
Note that I have the world's oldest scanner and for some reason my computer
does not have Microsoft Word. You can still make out the Questionnaire.
Many of the strange looking characters are when the scanner tried to read
boxes for yes and no or just simple check boxes.
Peyronie's Patient Questionnaire
Patient's Name:___________________________
Date: ___________________Soc Sec #:_________
Age: Date of Birth:______
Race:
Height: Weight:
Address:
Work Phone: ____________Home Phone: _____
Status: ~ Single ~ Married How many years?
Divorced LI] Widowed How many years?
Partner Regular Occasional
Referring doctor and attending physician:
Name:________________________________
Address:_______________________
Are there any medical records?_____________________
If yes, Hospital ID/Chart Number: ____________________
How long have you had this problem?
What was the first symptom of Peyronie's Disease?
When?
How long before you saw a physician once symptoms
occurred?
Date and place of diagnosis:
Click for next page
When you developed Peyronies Disease you were probably in a state of
shock and had no idea about was going on. During your visit to the urologist,
it is certain that you did not know what questions to ask in order to assist him
in performing a thorough examination. The probability is that he did not
perform an appropriate and comprehensive examination. For example, did
you know that if you have Peyronies you are at an increased risk for two
additional, related impairments; Dupuytren’s Contracture and Ledderhose
Disease? Who ever heard of these medical conditions before and did your
physician examine you for these conditions? The Devine Center for
Genitourinary Reconstruction at Sentara Norfolk General Hospital has
produced a Peyronie’s Patient Questionnaire.
It is very through and I strongly suggest that you print it out and then
complete it. It will help you organize the information about your Peyronies
and assist you in guiding your physician so you will get the most out of your
office visit. This is definitely worthwhile.
Note that I have the world's oldest scanner and for some reason my computer
does not have Microsoft Word. You can still make out the Questionnaire.
Many of the strange looking characters are when the scanner tried to read
boxes for yes and no or just simple check boxes.
Peyronie's Patient Questionnaire
Patient's Name:___________________________
Date: ___________________Soc Sec #:_________
Age: Date of Birth:______
Race:
Height: Weight:
Address:
Work Phone: ____________Home Phone: _____
Status: ~ Single ~ Married How many years?
Divorced LI] Widowed How many years?
Partner Regular Occasional
Referring doctor and attending physician:
Name:________________________________
Address:_______________________
Are there any medical records?_____________________
If yes, Hospital ID/Chart Number: ____________________
How long have you had this problem?
What was the first symptom of Peyronie's Disease?
When?
How long before you saw a physician once symptoms
occurred?
Date and place of diagnosis:
Click for next page