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Patient Information
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Occupation:
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Height:
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Weight:
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Reason for your visit:
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What city do you live in?
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Did you have anything to eat today?
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New Yes / No
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New Short Text Field
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My Medical History:
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If yes, please explain
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Any medical conditions?
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Do you have Diabetes?
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New Yes / No
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Bleeding Disorders?
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New Yes / No
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Penile Implants or past procedures?
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New Yes / No
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Are you on blood thinning medications?
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New Yes / No
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Autoimmune diseases, healing problems?
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New Yes / No
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Penile Ulcers, STD's, Herpes?
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New Yes / No
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History of cancer or cancer treatments?
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New Yes / No
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Are you currently on antibiotics?
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New Yes / No
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Do you have Erectile Dysfunction?
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New Yes / No
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HIV?
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New Yes / No
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Are you circumcised (cut)?
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New Yes / No
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Any raised scars (keloids)?
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New Yes / No
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Do you suffer of Anxiety or Depression?
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New Yes / No
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Panic Attacks?
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New Yes / No
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Do you faint when you see blood?
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New Yes / No
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Family History:
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Any medical conditions that run in your family?
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Lifestyle questions:
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Do you smoke?
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New Yes / No
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Do you drink alcohol?
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New Yes / No
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Do you take any narcotic?
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New Yes / No
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Illegal substances?
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New Yes / No
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Are you married?
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New Yes / No
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Domestic partner, significant other?
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New Yes / No
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Medications:
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Do you take any medications?
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Allergies
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Are you allergic to any medication?
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New Yes / No
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