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Peyronie’s Disease Questionnaire
Home
Peyronie’s Disease Questionnaire
Peyronie’s Disease
Step
1
of
20
5%
Name
(Required)
First Name
Family Name
Phone Number
(Required)
(By entering your phone number, you consent to be contacted through call and/or text on the phone number you enter.)
Email
(Required)
(By entering your email address, you consent to be contacted via email at the email address you provide.)
I opt to receive promotional information and clinic announcements on this number
I opt to receive promotional information and clinic announcements on this email
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)
Describe the direction of the bend (choose as many as apply)
Up
Down
Right
Left
International Index of Erectile Function (IIEF-5)
(without pills)
Answer the following questions considering your sexual function without taking any pills like Viagra or Cialis (if applicable):
1. OVER THE PAST 6 MONTHS, how do you rate your confidence that you could get and keep an erection? (Without pills)
Very low
Low
Moderate
High
Very high
2. OVER THE PAST 6 MONTHS, when you had erections with sexual stimulation, how often were your erections hard enough for penetration? (Without pills)
Almost never/never
A few times (much less than half the time)
Sometimes (about half the time)
Most times (much more than half the time)
Almost always/always
3. OVER THE PAST 6 MONTHS, during sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner? (Without pills)
Almost never/never
A few times (much less than half the time)
Sometimes (about half the time)
Most times (much more than half the time)
Almost always/always
4. OVER THE PAST 6 MONTHS, during sexual intercourse, how difficult was it to maintain your erection to completion of intercourse? (Without pills)
Extremely difficult
Very difficult
Difficult
Slightly difficult
Not difficult
5. OVER THE PAST 6 MONTHS, when you attempted sexual intercourse, how often was it satisfactory for you? (Without pills)
Almost never/never
A few times (much less than half the time)
Sometimes (about half the time)
Most times
Almost always or always
International Index of Erectile Function (IIEF-5)
(with pills)
Answer the following questions considering your sexual function with the help of pills like Viagra or Cialis (if applicable):
1. OVER THE PAST 6 MONTHS, how do you rate your confidence that you could get and keep an erection? (With pills - if applicable)
Very low
Low
Moderate
High
Very high
2. OVER THE PAST 6 MONTHS, when you had erections with sexual stimulation, how often were your erections hard enough for penetration? (With pills - if applicable)
Almost never/never
A few times (much less than half the time)
Sometimes (about half the time)
Most times (much more than half the time)
Almost always/always
3. OVER THE PAST 6 MONTHS, during sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner? (With pills - if applicable)
Almost never/never
A few times (much less than half the time)
Sometimes (about half the time)
Most times (much more than half the time)
Almost always/always
4. OVER THE PAST 6 MONTHS, during sexual intercourse, how difficult was it to maintain your erection to completion of intercourse? (With pills - if applicable)
Extremely difficult
Very difficult
Difficult
Slightly difficult
Not difficult
5. OVER THE PAST 6 MONTHS, when you attempted sexual intercourse, how often was it satisfactory for you? (With pills - if applicable)
Almost never/never
A few times (much less than half the time)
Sometimes (about half the time)
Most times
Almost always or always
Penis hardness score:
How would you describe your penis situation when you get your best erection (without pills)?
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
How would you describe your penis situation when you get your best erection (with pills – if applicable)?
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?
Yes
No
Have you been diagnosed with Dupuytren contracture?
Yes
No
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.
