Erectile Dysfunction & Peyronie's Disease Treatments
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Concerns
Erectile Dysfunction
Peyronie’s Disease
Frenulum Breve
Treatments
Shockwave Therapy
PRP Injection Therapy
Penile Frenulectomy
Sex Therapy
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RevibeMD
Our Doctor
Clinic Locations
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Contact
Contact Us
Book a Consult
Registration
Menu
Concerns
Erectile Dysfunction
Peyronie’s Disease
Frenulum Breve
Treatments
Shockwave Therapy
PRP Injection Therapy
Penile Frenulectomy
Sex Therapy
ED Quiz
About us
RevibeMD
Our Doctor
Clinic Locations
Blog
Contact
Contact Us
Book a Consult
Registration
306-373-8423
Registration
Please complete the details below before your initial appointment. Thanks
PATIENT INFORMATION
Name*
*
First
Last
Health card number
Date of birth*
*
DD slash MM slash YYYY
Age*
*
Address*
*
Street Address
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Preferred phone*
*
Secondary phone*
Email*
*
FAMILY DOCTOR INFORMATION
Family Doctor*
*
Doctor's Phone
Doctor's Location or City
Do you consent to our office communicating with your doctor?*
*
No
Yes
PERSONAL HISTORY
Occupation*
*
Relationship status*
*
Number of children*
*
Are you planning to have more children?*
*
No
Yes
How often do you exercise in a week and for how much each time?*
*
Do you smoke?*
*
No
Yes
Please quantify the amount per DAY:
Do you drink alcohol?*
*
No
Yes
Please quantify the amount per WEEK:
Do you use any recreational/illicit drugs?*
*
No
Yes
Type and frequency of use:
Do you use or have used anabolic steroids in the past?*
*
No
Yes
If yes, please specify type, frequency of use, and the time the last anabolic steroid use :
MEDICAL & SURGICAL HISTORY
Do you have a history of heart disease, congestive heart failure, high blood pressure, elevated cholesterol?*
*
No
Yes
Please specify:
Do you currently have a pacemaker, Implantable Cardioverter Defibrillator (ICD), or any other forms of internal/implantable electrical device in your body?*
*
No
Yes
Please specify the type of the electrical device and its location:
Do you have a history of metabolic disease such as Diabetes Mellitus?*
*
No
Yes
Please specify:
Do you have a history of neurological disorder such as spinal cord injury, head trauma, brain tumour, stroke, mini-stroke/TIA, Parkinson’s disease, Multiple Sclerosis, Epilepsy, etc.?*
*
No
Yes
Please specify:
Do you have any history of pelvic fracture or trauma?*
*
No
Yes
Please specify the time and the nature of the injury:
Do you have a known or suspected history of prostate cancer?*
*
No
Yes
If yes, please specify:
Do you have a history of abnormal prostate exam, Prostatic Hyperplasia (BPH), elevated PSA?*
*
No
Yes
If yes, please specify:
Do you have a history of prostate biopsy?*
*
No
Yes
If yes, please specify:
Have you ever had TURP surgery for benign prostatic hyperplasia (BPH)?*
*
No
Yes
What year?
Have you ever had a history of chemotherapy or radiation therapy?*
*
No
Yes
Please specify:
Do you have a history of trauma to the testicles, testicular torsion, orchitis, or undescented testicles?*
*
No
Yes
If yes, please specify:
Do you have a history of MUMPS?*
*
No
Yes
If yes, please specify:
Do you have a known or suspected history of breast cancer?*
*
No
Yes
If yes, please specify:
Do you have a history or symptoms of low testosterone (hypogonadism) such as low libido or sex drive, reduced morning erection, lack of energy, etc.?*
*
No
Yes
Are you currently on testosterone therapy?*
*
No
Yes
If yes, please specify the type, dosage and frequency.
Have you ever had a current or past history of low platelet count?*
*
No
Yes
What is the most recent platelet level?
Have you ever had a current or past history of anemia (low hemoglobin count)?*
*
No
Yes
What is the most recent hemoglobin level?
Do you have a history of bleeding disorder or hematological disorder (e.g. leukemia, sickle cell anemia)?*
*
No
Yes
Please specify:
Do you have a history of thickened blood? (Polycythemia)*
*
No
Yes
If yes, please specify:
Do you have current or past history of genital warts (HPV infection)?*
*
No
Yes
When was the last episode?
Do you have current or past history of genital herpes (HSV infection)?*
*
No
Yes
When was the last episode?
Have you tested positive for human immunodeficiency virus (HIV)?*
*
No
Yes
If yes, please specify:
Have you tested positive for tuberculosis (TB)?*
*
No
Yes
If yes, please specify:
Have you tested positive for hepatitis (A, B or C)?*
*
No
Yes
If yes, please specify:
Do you have a history of depression, anxiety, bipolar disorder, or other psychological disorders?*
*
No
Yes
Please specify:
Do you have a history of obstructive sleep apnea?*
*
No
Yes
Are you currently on CPAP therapy?
Do you have any history of malignancy (cancer)?*
*
No
Yes
Please specify:
Do you have any other medical history that is not included in the above list?*
*
No
Yes
Please specify:
Do you have any other significant surgical history that was not included in the above list?*
*
No
Yes
Please specify:
MEDICATIONS
Are you taking any blood thinner such as Aspirin, Plavix (Clopidogrel), Warfarin (Coumadin), Rivaroxaban (Xarelto), Apixaban (Eliquis), Dabigatran (Pradaxa)?*
*
No
Yes
Type: | Dose: | Frequency:
Do you have current or past history of Finasteride use?*
*
No
Yes
What dosage/frequency?
Do you have a history or Androgenic Anabolic Steroid use, Opioid use, Corticosteroid use, antiseizure (anticonvulsants) or antifungal medications?*
*
No
Yes
Please specify:
Please list the other medications that you are currently taking, including the reason, dosage, and frequency.*
*
Example: Ciprelax, 20mg once a day for anxiety - or "none"
ALLERGY
Drug | Type of reaction. Enter "none" if no allergies.
*
Are you allergic to lidocaine (freezing agent)?*
*
No
Yes
Type:
Are you allergic to tetracaine (freezing agent)?*
*
No
Yes
Type:
FAMILY HISTORY
Please select all that apply:*
*
Prostate cancer
Benign prostate hyperplasia (BPH)
Hypogonadism (low testosterone)
Erectile dysfunction
None of the above
HISTORY OF SEXUAL FUNCTION
Have you noticed a decline in your sexual performance?*
*
No
Yes
For how long?
*
If you have been suffering from erectile dysfunction (ED) how long has it been?*
*
Have you ever been able to achieve erection with self-stimulation (masturbation) without any pills?*
*
No
Yes
Do you wake up with morning erections?*
*
No
Yes
How often in a month?*
*
How long does it last in the morning?*
*
Do you have any issues with ejaculation?*
*
No
Yes
Do you have any issues with orgasm?*
*
No
Yes
Do you experience erectile dysfunction in certain positions such as lying down, upon getting up, or seated?*
*
No
Yes
Please specify:
What is your idea about the cause of your erectile dysfunction?*
*
Erection Hardness Score - Please respond to describe your erections when you are not taking pills or other erection aids.
How would you rate the hardness of your erection when you are NOT using pills, injections or supplements (Viagra, Cialis, Levitra)?*
*
Penis does not enlarge
Penis is larger, but not hard
Penis is hard, but not hard enough for penetration
Penis is hard enough for penetration, but not completely hard
Penis is completely hard and fully rigid
IIEF Questionnaire - Please respond to describe your sexual performance over the last 4 weeks.
In the last 4 weeks were you using pills, injections, or supplements (Viagra, Cialis, Levitra, etc)?*
*
No
Yes
How often were you able to get an erection during sexual activity?*
*
No sexual activity
Almost never or never
A few times (less than half the time)
Sometimes (about half the time)
Most times (more than half the time)
Almost always or always
When you had erections with sexual stimulation, how often were your erections hard enough for penetration?*
*
No sexual activity
Almost never or never
A few times (less than half the time)
Sometimes (about half the time)
Most times (more than half the time)
Almost always or always
When you attempted intercourse, how often were you able to penetrate (enter) your partner?*
*
Did not attempt intercourse
Almost never or never
A few times (less than half the time)
Sometimes (about half the time)
Most times (more than half the time)
Almost always or always
During sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner?*
*
Did not attempt intercourse
Almost never or never
A few times (less than half the time)
Sometimes (about half the time)
Most times (more than half the time)
Almost always or always
During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?*
*
Did not attempt intercourse
Extremely difficult
Very difficult
Difficult
Slightly difficult
Not difficult
How do you rate your confidence that you could get and keep an erection?*
*
Very low
Low
Moderate
High
Very high
RISK FACTORS FOR ERECTILE DYSFUNCTION
Do you ride a bicycle regularly?*
*
No
Yes
Have you injured your spinal cord?*
*
No
Yes
What year?
Have you had your prostate removed for cancer?*
*
No
Yes
What year?
Have you undergone radiation therapy for prostate cancer?*
*
No
Yes
What year?
Have you had prostate surgery (TURP) for benign prostatic growth?*
*
No
Yes
What year?
PEYRONIE’S DISEASE SPECIFIC QUESTIONS:
Have you ever injured your penis?*
*
No
Yes
What year?
Has your penis ever been forcibly bent while erect?*
*
No
Yes
What year?
Do you have a history of Peyronie’s disease or penile fracture or rupture?*
*
No
Yes
Please specify (including previous treatment plans):
Have you had a straddle injury?*
*
No
Yes
Do you have a history of penile injection(s) such as Trimix, Caverject, etc. ?*
*
No
Yes
Please specify (type and date):
What direction does your penis bend towards when erect?*
*
Up
Down
Left
Right
Do you feel any pain with erection?*
*
No
Yes
Is the penile curvature interfering with intercourse?*
*
No
Yes
PREMATURE EJACULATION DIAGNOSTIC TOOL
How difficult is it for you to delay ejaculation? What is the time between penetration and ejaculation?*
*
Not difficult at all
Somewhat difficult
Modaretely difficult
Very difficult
Extremely difficult
Do you ejaculate before you want to?*
*
Almost never or never
Less than half the time
About half the time
More than half the time
Almost always or always
Do you ejaculate with very little stimulation?*
*
Almost never or never
Less than half the time
About half the time
More than half the time
Almost always or always
Do you feel frustrated because of ejaculating before you want to?*
*
Not at all
Slightly
Moderately
Very
Extremely
How concerned are you that your time to ejaculation leaves your partner unfulfilled?*
*
Not at all
Slightly
Moderately
Very
Extremely
How long does it usually take for you to ejaculate during intercourse?*
*
Less than 1 minute
Between 1 and 3 minutes
Beyond 3 minutes
Have you been having premature ejaculation since your first experience of sexual intercourse and with every partner?*
*
Yes
No
Please explain :
What type of treatment(s) have you had in the past for premature ejaculation? Please be specific regarding the type of treatment
Include any medication and dosages and their effectiveness for you, the year of the treatment and the treating physician(s). Enter "none" if none
PREVIOUS EVALUATION
Have you ever received a penile injection?*
*
No
Yes
Did it produce a full erection?
No
Yes
Have you undergone a penile blood flow study?*
*
No
Yes
What was the result?
Normal
Abnormal
Have you undergone testing of erections during sleep?*
*
No
Yes
What was the result?
Normal
Abnormal
ADAM TEST
Have you experienced a decrease in your sex drive (libido)?*
*
Yes
No
Do you lack energy or feel weak?*
*
Yes
No
Has your strength or endurance decreased?*
*
Yes
No
Have you lost height?*
*
Yes
No
Have you noticed yourself enjoying life less?*
*
Yes
No
Are you frequently sad or particularly irritable?*
*
Yes
No
Are your erections less strong?*
*
Yes
No
Have you noticed a recent deterioration in your athletic ability?*
*
Yes
No
Do you find yourself falling asleep after dinner?*
*
Yes
No
Has there been a recent deterioration in your work performance?*
*
Yes
No
PREVIOUS TREATMENT AND RESPONSES
Have you ever tried PDE5-inhibitors (Viagra, Levitra or Cialis)?*
*
No
Yes
How was your response to PDE5-inhibitors?
I am able to obtain and maintain erection all the time with PDE5-inhibitors.
I inconsistently respond to PDE5-inhibitors
I do not respond to PDE5-inhibitors at all
Did PDE5-inhibitors work to your satisfaction?
No
Yes
Do you experience any side effects related to PDE5-inhibitors (Viagra, Levitra or Cialis)?
No
Yes
Please specify the side effects:
Do you like taking these pills?
No
Yes
Have you tried MUSE therapy (intraurethral prostaglandin)?*
*
No
Yes
Did the MUSE work for you?
No
Yes
Do you like using the MUSE?
No
Yes
Have you tried Caverject (Intracavernosal injectable prostaglandin)?*
*
No
Yes
Did the Caverject work for you?*
*
No
Yes
Do you like using the Caverject?
No
Yes
Have you tried the vacuum erection device (VED)?*
*
No
Yes
Did the VED work for you?
No
Yes
Do you like the VED?
No
Yes
Have you ever had penile prosthesis (implant) surgery?*
*
No
Yes
What year?
Are you interested in the option of penile prosthesis surgery for your erectile dysfunction?
No
Yes
EXPECTATIONS
*What are your expectations for the visit?
*
To explore options for ED Treatment
To expore the option of Penile Enlargement
To explore options for Peyronie's Disease Treatment
To explore options for Premature Ejaculation Treatment
To explore options for Delayed Ejaculation Treatment
To explore options for Sex Therapy
To explore the option of a Testosterone Assessment
To explore the option of Frenulum Breve Treatment
Other:
Please describe
How did you hear about us?
Please check ALL the options that led you to the clinic:
Doctor’s referral / recommendation
Name of family doctor / walk-in clinic / urologist:
Family / friend
My wife / partner sent me
I am a past patient
Online
Online ad
Online search
Online article
Social Media
Facebook
Instagram
Twitter
What source was the MOST INFLUENTIAL in bringing you to our clinic?*
*
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