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ERECTILE DYSFUNCTION
TESTOSTERONE REPLACEMENT THERAPY
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Request Appointment For Consultation
"e-Appointment"
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New Patient?
Yes
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Name
Email address
Mobile Phone Number
Date of Birth
9:00 am
10:00 am
11:00 am
12:00 pm
1:00 pm
2:00 pm
3:00 pm
4:00 pm
5:00 pm
6:00 pm
7:00 pm
8:00 pm
9:00 pm
Health History
Medications if Any
High or Low Blood Pressure
Y
N
Diabetes Mellitus
Y
N
Kidney Problems(renal failure)
Y
N
Liver Issues
Y
N
Prostate Problems or Surgery
Y
N
Bladder Problems or Surgery
Y
N
Do You Smoke
Y
N
Do You Smoke Marijuana
Y
N
Do You Drink Alcohol
Y
N
Have You Had A Heart Attack Or Do You Have Heart Disease?
Y
N
Has Your Primary Physician Told You Were Healthy Enough For Sex?
Y
N
Do You Have Morning Erections
Y
N
How Long Does Your Typical Erection Last
How HARD Does Your Erection Get
NOT MUCH
SOME
FIRM
Do You Ejaculate Prior To
OR Soon After Penetration
Y
N
Please note: New patient visits are typically 1/2 hours. Our practice will call you to confirm your appointment