Erectile Dysfunction Intake Form

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Name* This field is required.
First Name
Last Name
2
Date of Birth* This field is required.
Date
Year
Month
Day
3
Age* This field is required.
4
Gender* This field is required.
Male
Female
5
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
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Fiji
Finland
France
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Italy
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Liberia
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Mali
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Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
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United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
6
Phone Number* This field is required.
Area Code
Phone Number
7
Email* This field is required.
example@example.com
8
Marital Status* This field is required.
Single
Married
Divorced
Widowed
9
Emergency Contact* This field is required.
Name / Relationship
Phone Number 1
Phone Number 2
10
Current Supplement ListList all supplements currently you are taking.
11
Drivers License Number* This field is required.
12
Driver License FRONT Picture upload.* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
13
How often are you currently sexually active?* This field is required.
Daily
Weekly
Monthly
Other
14
Other, please elaborate.* This field is required.
15
How long have you struggled erectile dysfunction?* This field is required.
For a few months
Within the last 30 days
For 1-2 years
Over 2 years
16
Which erectile dysfunction treatments have you tried?* This field is required.
Over the counter products
Topical treatments
Viagra
Cialis
Other
17
Since you selected "other" can you please elaborate?* This field is required.
18
Do you wake up in the morning with an erection?* This field is required.
Yes, daily
Yes, most days
No
Never
Other
19
Since you selected "other" can you please elaborate? * This field is required.
20
Which best describes your desire to have sex?* This field is required.
I always want to have sex
My desire for sex has decreased significantly
I have no sex desire
Other
21
Since you selected "other" can you please elaborate?* This field is required.
22
Have you ever been prescribed erectile dysfunction medication from a physician?* This field is required.
YESNO
23
Are you able to maintain an erection when masturbating?* This field is required.
Yes
No
Other
24
Since you selected "other" can you please elaborate? * This field is required.
25
When was your last physical exam?* This field is required.
Within 1 year
Within 2 years
Never
2-5 years ago
26
Do you have any medication allergies?* This field is required.
YESNO
27
Yes, please list * This field is required.
28
When was your last lab screening completed?* This field is required.
Less than 1 year
1-2 years
2-5 years
Over 5 years ago
29
Blood pressure is essential for us to provide quality care for erectile dysfunction treatment. Which number range best represents your top blood pressure number normally? (Example 120/80 the 120 would be the top number)* This field is required.
95-125
125-145
145-165
Over 165
Other
30
Since you selected "other" can you please explain? * This field is required.
31
Blood pressure is essential for us to provide quality care for erectile dysfunction treatment. Which number range best represents your bottom blood pressure number normally? (Example 120/80 the 80 would be the bottom number)* This field is required.
69-80
80-90
90-99
Over 99
Other
32
Since you selected "other" can you please explain? * This field is required.
33
When is the last time you checked your blood pressure?* This field is required.
Within the last month
1-2 months
2-5 months
Over 5 months
34
Have you ever been diagnosed with high blood pressure?* This field is required.
YESNO
35
Do you currently take any medications containing nitrates?* This field is required.
Yes
No
Unsure
Other
36
Since you selected "other" can you please explain?* This field is required.
37
Do you currently take any prescription medications?* This field is required.
YESNO
38
Current Medication List (please list all medications that you are currently taking).List all medications currently prescribed to you by any doctor. This includes medications prescribed on a regular basis here, by your primary care physician, and any other doctor you see.
39
Have you been diagnosed with any medical conditions?* This field is required.
YESNO
40
Yes, please list * This field is required.
41
Have you had previous surgeries?* This field is required.
YESNO
42
Yes, please list * This field is required.
43
Please check all that apply to you:* This field is required.
High cholesterol
High blood pressure
Diabetes
Heart attacks
Mother or father had a heart attack or heart disease
None of the above apply
44
Do you have any of the following medical conditions? * This field is required.
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
HIV
Hepatitis C
Low Blood Pressure
Heart Attack or Heart Failure
Any blood clotting disorder
Stroke
Auto-immune Diseases
Leukemia
Sickle Cell Anemia
Retinitis pigmentosa
Idiopathic hypertrophic subaortic stenosis
Renal Failure
Any history of QT prolongation in you or family members
HIV
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
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45
Do you have any of the following?* This field is required.
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
Pain with erections
Pain with ejaculation
Foreskin is too tight
Peyronie’s Disease
A curve or bend in the penis that interferes with sex
Lumps and bumps under the skin of the penis
Pain with erections
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
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Have you ever had any of the following conditions?* This field is required.
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
Liver Disease
Kidney transplant
Surgery or radiation to the prostate
Surgery or radiation to the penis
Multiple Sclerosis or similar neurological diseases
Intestinal, bowel, or stomach ulcers
Heart arrhythmias / abnormal heart beats
Any abnormalities of the heart including murmurs
Liver Disease
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
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47
Erectile Dysfunction can be associated with certain health conditions. Including but not limited to cardiovascular issues. Have you had any of the following?* This field is required.(Check all that apply)
Yes
Rapid, unusually slow, or irregular heartbeats
Row 0, Column 0
Chest pain or shortness of breath while doing activities
Row 1, Column 0
Fainting episodes
Row 2, Column 0
Dizziness
Row 3, Column 0
Cramping in calves or thighs
Row 4, Column 0
None of the above apply
Row 5, Column 0
Rapid, unusually slow, or irregular heartbeats
Chest pain or shortness of breath while doing activities
Fainting episodes
Dizziness
Cramping in calves or thighs
None of the above apply
Yes
Row 0, Column 0
Yes
Row 1, Column 0
Yes
Row 2, Column 0
Yes
Row 3, Column 0
Yes
Row 4, Column 0
Yes
Row 5, Column 0
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Do you smoke cigarettes or cigars?* This field is required.
YESNO
49
Do you drink alcohol?* This field is required.
YESNO
50
Do you use recreational drugs?* This field is required.
YESNO
51
Yes, please list * This field is required.
52
Do you exercise regularly?* This field is required.
Yes
No
Sometimes
Other
53
Since you selected "other" can you please explain? * This field is required.
54
Consent to Erectile Dysfunction Treatment* This field is required.
55
Consent to Erectile Dysfunction Treatment Signature* This field is required.
Clear
56
Patient Release of InformationPlease list anyone whom we may inform of your medical condition and diagnosis (including appointment, treatment, payment, and health care concerns). If the name is not listed, we are legally unable to give out any information regardless of the relationship with the patient. If you wish to list additional people, you may do so under your signature. You may remove a person’s name from this list at any time by simply contacting our office.
Full Name
Please enter your phone
Address / City / Zip Code
57
Patient Release of Information Signature* This field is required.
Clear
58
Padgett Medical Terms and Conditions* This field is required.
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Padgett Medical Terms and Conditions Signature* This field is required.
Clear
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HIPAA Information Release & Disclosure Notice* This field is required.
61
HIPAA Information Release & Disclosure Notice(Health Insurance Portability and Accountability Act) Signature* This field is required.
Clear
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HIPAA Release of Information Authorization Form

Patient authorizes Padgett Medical Center, LLC to request any and all medical records, x-rays, or any diagnostic testing results from any and all medical providers involved in my medical care past or present. Please forward any and all documents requested to the attention of the provider at this fax number below.

Tampa office Fax (813) 908-7711

Ocala office Fax (352) 369-0107

By signing this authorization, I understand that medical records released may contain
information related to HIV status, aids, sexually transmitted diseases, mental health, and alcohol abuse, etc. I understand that release of psychotherapy notes requires additional authorization. NOTE: If the information you are authorizing for release by signing this form involves alcohol or drug abuse, you must also sign a special authorization that is separate from this one, alcohol and drug abuse information is protected by federal law (FEDERAL REGULATIONS 42 CFR PART 2) and will not be shared with anyone else unless you sign a separate form.

{name}

{dateOf}
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HIPAA Release of Information Authorization Form Signature* This field is required.
Clear
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Patient Rights and Responsibilities* This field is required.
65
Patient Rights and Responsibilities Signature* This field is required.
Clear
66
Informed Consent for Telehealth Services* This field is required.
67
Informed Consent for Telehealth Services Signature* This field is required.
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Please verify that you are human* This field is required.
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