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(289) 632-8825

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PATIENT INFORMATION
Name*
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Name
First Last
Date of birth*
Day
Month
Year
Health Card (OHIP) if available*
Age*
Address*
Street Address City Province Postal Code
Home phone*
Preferred Number (if different)*
Email*
FAMILY DOCTOR INFORMATION
Family Doctor*
Doctor's Phone
PERSONAL HISTORY
Occupation*
Relationship status*
How often do you exercise in a week and for how much each time?*
Do you smoke?*
- No
- Yes
Please quantify the amount per DAY:
Do you drink alcohol?*
- No
- Yes
Please quantify the amount per WEEK:
Do you use any recreational/illicit drugs?*
- No
- Yes
Type and frequency of use:
Do you use or have used anabolic steroids in the past?*
- No
- Yes
If yes, please specify type, frequency of use, and the time the last anabolic steroid use :
MEDICAL & SURGICAL HISTORY
Do you have a history of heart disease, congestive heart failure, high blood pressure, elevated cholesterol?*
- No
- Yes
Please specify:
Do you currently have a pacemaker, Implantable Cardioverter Defibrillator (ICD), or any other forms of internal/implantable electrical device in your body?*
- No
- Yes
Please specify the type of the electrical device and its location:
Do you have a history of metabolic disease such as Diabetes Mellitus?*
- No
- Yes
Please specify:
Do you have a history of neurological disorder such as spinal cord injury, head trauma, brain tumour, stroke, mini-stroke/TIA, Parkinson’s disease, Multiple Sclerosis, Epilepsy, etc.?*
- No
- Yes
Please specify:
Do you have any history of pelvic fracture or trauma?*
- No
- Yes
Please specify the time and the nature of the injury:
Do you have a known or suspected history of prostate cancer?*
- No
- Yes
If yes, please specify:
Do you have a history of abnormal prostate exam, Prostatic Hyperplasia (BPH), elevated PSA?*
- No
- Yes
If yes, please specify:
Do you have a history of prostate biopsy?*
- No
- Yes
If yes, please specify:
Have you ever had TURP surgery for benign prostatic hyperplasia (BPH)?*
- No
- Yes
What year?
Have you ever had a history of chemotherapy or radiation therapy?*
- No
- Yes
Please specify:
Do you have a history of trauma to the testicles, testicular torsion, orchitis, or undescented testicles?*
- No
- Yes
If yes, please specify:
Do you have a history of MUMPS?*
- No
- Yes
If yes, please specify:
Do you have a known or suspected history of breast cancer?*
- No
- Yes
If yes, please specify:
Do you have a history or symptoms of low testosterone (hypogonadism) such as low libido or sex drive, reduced morning erection, lack of energy, etc.?*
- No
- Yes
Are you currently on testosterone therapy?*
- No
- Yes
If yes, please specify the type, dosage and frequency.
Have you ever had a current or past history of low platelet count?*
- No
- Yes
What is the most recent platelet level?
Have you ever had a current or past history of anemia (low hemoglobin count)?*
- No
- Yes
What is the most recent hemoglobin level?
Do you have a history of bleeding disorder or hematological disorder (e.g. leukemia, sickle cell anemia)?*
- No
- Yes
Please specify:
Do you have a history of thickened blood? (Polycythemia)*
- No
- Yes
If yes, please specify:
Do you have current or past history of genital warts (HPV infection)?*
- No
- Yes
When was the last episode?
Do you have current or past history of genital herpes (HSV infection)?*
- No
- Yes
When was the last episode?
Have you tested positive for human immunodeficiency virus (HIV)?*
- No
- Yes
If yes, please specify:
Have you tested positive for tuberculosis (TB)?*
- No
- Yes
If yes, please specify:
Have you tested positive for hepatitis (A, B or C)?*
- No
- Yes
If yes, please specify:
Do you have a history of depression, anxiety, bipolar disorder, or other psychological disorders?*
- No
- Yes
Please specify:
Do you have a history of obstructive sleep apnea?*
- No
- Yes
Are you currently on CPAP therapy?
Do you have any history of malignancy (cancer)?*
- No
- Yes
Please specify:
Do you have any other medical history that is not included in the above list?*
- No
- Yes
Please specify:
Do you have any other significant surgical history that was not included in the above list?*
- No
- Yes
Please specify:
ALLERGY *
Drug | Type of reaction. Enter "none" if no allergies.*
Are you allergic to lidocaine (freezing agent)?*
- No
- Yes
Type:
Are you allergic to tetracaine (freezing agent)?*
- No
- Yes
Type:
HISTORY OF SEXUAL FUNCTION
Have you noticed a decline in your sexual performance?*
- No
- Yes
For how long?*
Do you experience some degree of erectile dysfunction?*
- No
- Yes
For how long?*
Have you ever been able to achieve erection with self-stimulation (masturbation) without any pills?*
- No
- Yes
Do you wake up with morning erections?*
- No
- Yes
How often in a month?*
How long does it last in the morning?*
Do you have any issues with ejaculation?*
- No
- Yes
Do you have any issues with orgasm?*
- No
- Yes
Do you experience erectile dysfunction in certain positions such as lying down, upon getting up, or seated?*
- No
- Yes
Please specify:
What is your idea about the cause of your erectile dysfunction?*
RISK FACTORS FOR ERECTILE DYSFUNCTION
Do you ride a bicycle regularly?*
- No
- Yes
Have you injured your spinal cord?*
- No
- Yes
What year?
Have you had your prostate removed for cancer?*
- No
- Yes
What year?
Have you undergone radiation therapy for prostate cancer?*
- No
- Yes
What year?
Have you had prostate surgery (TURP) for benign prostatic growth?*
- No
- Yes
What year?
PEYRONIE’S DISEASE SPECIFIC QUESTIONS:
Have you ever injured your penis?*
- No
- Yes
What year?
Has your penis ever been forcibly bent while erect?*
- No
- Yes
What year?
Do you have a history of Peyronie’s disease or penile fracture or rupture?*
- No
- Yes
Please specify (including previous treatment plans):
Have you had a straddle injury?*
- No
- Yes
Do you have a history of penile injection(s) such as Trimix, Caverject, etc. ?*
- No
- Yes
Please specify (type and date):
What direction does your penis bend towards when erect?*
- Up
- Down
- Left
- Right
Do you feel any pain with erection?*
- No
- Yes
Is the penile curvature interfering with intercourse?*
- No
- Yes
MEASLES SCREENING
Do you or anyone in your household currently have a rash?*
- No
- Yes
Have you or anyone in your household developed a fever in the last 4 days?*
- No
- Yes
Do you or anyone in your household have any of the following respiratory symptoms?*
- Cough
- Runny Nose
- Congestion
- No/None
Do you or anyone in your household currently have a sore throat, conjunctivitis or watery eyes?*
- No
- Yes
Have you or anyone in your household been in contact with someone who has tested positive for Measles in the last 21 days?*
- No
- Yes

Because sexual wellness is an integral part of your health and happiness.

Contact us for more information

Mississauga Erectile Dysfunction Clinic for Men

Book a Consultation

10 Kingsbridge Garden Circle
Suite 305
Mississauga, ON L5R 3K6

77 Hunter Street East
Hamilton, ON L8N 1M4

51 Benton Street
Kitchener, ON N2G 3H1

180 Vine St S Unit 201
St. Catharines, ON L2R 7P3

672 Brant Street, Suite 200
Burlington, ON L7R 2H3

195 Henry St, Unit 05
Brantford, ON N3S 5C9

Tel: (289) 632-8825

Fax: (905) 502-1426

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CONCERNS

ERECTILE DYSFUNCTION
PEYRONIE'S DISEASE
LOW TESTOSTERONE
PREMATURE EJACULATION
PENIS ENLARGEMENT
DELAYED EJACULATION
FRENULUM BREVE
PENILE LICHEN SCLEROSUS

TREATMENTS

SHOCKWAVE THERAPY
INJECTION THERAPY
TRIMIX
NEUROMODULATORS
SEX THERAPY
PENILE FRENULECTOMY
LOW T QUIZ
ED QUIZ

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OAKWOOD HEALTH NETWORK

Registration

PATIENT INFORMATION

FAMILY DOCTOR INFORMATION

PERSONAL HISTORY

MEDICAL & SURGICAL HISTORY

ALLERGY *

HISTORY OF SEXUAL FUNCTION

RISK FACTORS FOR ERECTILE DYSFUNCTION

PEYRONIE’S DISEASE SPECIFIC QUESTIONS:

MEASLES SCREENING

Contact us for more information

Book a Consultation