1. Age *
   
   
2. Weight *
   
   
3. Ethnicity
   -- Please Select --CaucasianBlackMiddle EasternAsianAmerican IndianOther
4. If Other Ethnicity
   
   
5. Partner *
   Married
   Single
   Divorced
   Widowed
   
6. Partners Age *
   
   
7. Who diagnosed your PD? *
   Self
   Partner
   Primary Care Physician
   Urologist
   Other
   
8. Can you feel a Lump / Nodule / Plaque on your penis? *
   Yes
   No
   
9. Do you have curvature? *
   Yes
   No
   
10. Which direction?
    -- Please Select --UpDownRightLeft
11. How many Degrees is your curvature?
    Not Applicable10-2020-3030-4040-5050-6060-70Greater than 70
12. Do you have an Indentation? *
    Yes
    No
    
13. Do you have Penile pain? *
    In the Flaccid (Soft) State?
    In the Erect (Hard) State?
    
14. If you do not have pain at this time, did you previously? *
    Yes
    No
    
15. How long did you have pain for, before the pain went away?
    
    
16. Do you have Erection (hardness) problems since the start of PD? *
    Yes
    No
    
17. Is it difficult to penetrate your partner since the start of PD? *
    Yes
    No
    
18. Does the curvature cause your partner pain? *
    Yes
    No
    
19. Do you have any of the following conditions? *
    High Blood Pressure
    Diabetes
    High Cholesterol (Triglycerides)
    Heart Attack
    Angina (Cardiac Chest Pain)
    Heart Bypass Surgery
    Low Testosterone
    Coronary Artery Angioplasty
    Radical Prostatectomy
    Peripheral Vascular Disease
    Benign Prostate Surgery
    Lower Limb Bypass Surgery
    Prostate Radiation (External or Seeds)
    Stroke
    Prostate Enlargement
    Carotid Artery Surgery
    Depression
    Anxiety Disorder
    
20. If you answered yes to Depression, did this commence after your PD was diagnosed? *
    Yes
    No
    N/A
    
21. If you answered yes to Anxiety disorder, did this start after your PD was diagnosed? *
    Yes
    No
    N/A
    
22. Have you tried any treatments for PD? Please check the ones that apply from the list below: *
    Vitamin E
    Potaba
    Colchicine
    Acetyl-L-Carnitine
    Verapamil
    Verapamil Injections
    Interferon Injections
    Collagenase Injections
    ESWT
    Radiation Therapy
    
23. Have you had surgery for your PD? Which Type?
    NonePenile Plication Procedure (Tuck Procedure)Plaque Incision/Excision and GraftingPenile Implant Surgery
24. How long did you have PD before you had surgery?
    
    

* Required Fields