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Peyronie’s Disease Questionnaire
Home
Peyronie’s Disease Questionnaire
Peyronie’s Disease
Step
1
of
10
10%
Name
(Required)
First Name
Family Name
Phone Number
Email
(Required)
This questionnaire is for patients who are experiencing a bent or misshapen penis, sometimes referred to as Peyronie’s. Answers to these questions will enable the consulting physician to discuss treatment options. Your answers to the questions will be kept confidential. If you are unsure how to answer or feel uncomfortable answering any of the questions you can skip over them.
Do you have any tenderness or pain when you have intercourse?
Yes
No
How severe is the bend in your penis (in degrees)?
Less than 10˚ (a little)
10˚- 20˚ (medium)
20˚- 45˚ (severe)
More than 45˚ (extreme)
Describe the direction of the bend (choose as many as apply)
Up
Down
Right
Left
See what your erectile function score is
Click Here
Penis hardness score:
0 - Penis is flaccid
1 - Penis is larger than normal, but not hard
2 - Penis is hard, but not hard enough for penetration
3 - Penis is hard enough for penetration but not completely hard
4 - Penis is completely hard and fully rigid
Please rate the hardness of your penis relative to your expectation?
Very dissatisfied
Moderately dissatisfied
About equally satisfied and dissatisfied
Moderately satisfied
Very satisfied
List of medications:
List the prescription medications you are taking currently or recently.
Add
Remove
List the naturopathic and herbal medicines you take regularly.
Add
Remove
List other over-the-counter, non-prescription medications you take regularly.
Add
Remove
Do you have diabetes?
Have you been diagnosed with Dupuytren contracture?
Add
Remove
If you are comfortable, please bring two photos of your erect penis to your appointment: one from the top, the other from one side. This enables our medical personnel to recommend optimal treatments and to quantify the effects of treatments, if undertaken.
