Patient Questionnaire

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Patient Questionnaire

In order to provide you with the best possible results and treatment formula, it is imperative that our physicians fully understand your health conditions as well as your sexual complaints. Please take your time in answering the following questions and provide answers in as much details and accuracy as possible. Please submit this form PRIOR to your next appointment to allow time for review.

Your Name(Required)

First Last

Phone Number(Required)

Date of Birth(Required)

Month

Day

Year

Height(Required)

Weight(Required)

If you have ED, a) when did you first notice any problem and b) when did it become a significant problem that interferes with your sexual intercourse? Please elaborate(Required)

If you have ED, a) when did you first notice any problem and b) when did it become a significant problem that interferes with your sexual intercourse? Please elaborate(Required)

In the last 6 months, how strong are your erections that you can achieve on your own without using any ED medication?(Required)

Without using any ED medication, please indicate how strong are your own erections when you are sexually aroused, in the last 12 months or so ?(Required)

50% or Less (Unable to penetrate)

65% (Enough to penetrate but difficult)

80% (Able to penetrate with ease)

90% (Almost normal)

100% (Rigid)

Do you still experience nocturnal or early morning erections?(Required)

Yes

No

please indicate the percentage using the above scale(Required)

50% or Less

65%

80%

90%

100%

Can you achieve an erection with masturbation?(Required)

Yes

No

please indicate the percentage using the above scale(Required)

50% or Less

65%

80%

90%

100%

Do You Have PE (Premature Ejaculation)?(Required)

Yes, lifelong problem.

Yes, recent problem.

No.

Medical History(Required)

Check all that apply.

Diabetes

Hypertension

High Cholesterol

Heart Disease

Heart Attack

Angina

Heart Bypass or Angioplasty

Multiple Sclerosis

Cancer

Epilepsy

Stroke

Prostate Surgery

Peyronie's Plaque

Injuries or trauma to spine/pelvis/penis

Any other significant health issue

None

Angina: please indicate a) whether you have stable or unstable angina; b) level of fitness for sex as fit, fit enough or unfit

Cancer: Please indicate a) what kind b) treatment received c) whether you are now cancer free

Diabetes: Please indicate a) when it was first diagnosed; b) how well control the blood sugar has been; c) any known complications affecting the eyes, kidneys, etc.

Heart Bypass: Please indicate when it was performed and treatment outcome

Heart Attack: Please indicate when that happened and whether it was a mild, moderate or severe one

Stroke: Please indicate when that happened and whether it was a mild, moderate or severe one

Injuries or trauma to spine/pelvis/penis: Please Elaborate

Any other significant health issue: Please Elaborate

Are You interested in(Required)

Check all that apply

ED Shots / Injections (ICP or Trimix)

Stronger ED Pills (Erexafil™)

Libido and Sexual Response Enhancement (Bremetide™ / PT-141)

Control Premature Ejaculation (Tadexetine™)

Not Sure / Other

Please Describe

Are you taking Nitrates?(Required)

List medications you have used or are currently using to treat your condition. Describe its effectiveness by indicating the percentage of erection achieved using the above scale, the duration of best erection achieved, and any side-effects experienced. For example: 100 mg Viagra, 60% for 15 minutes. Flushing. If none, state “none”(Required)

Please list all current prescription medications accurately including strength, amount and number of times a day. If none, state “none”(Required)

List all known drug allergies? If none, state “none”(Required)

Please describe your ED/PE issues in as much details as possible including what you think as the cause of the problems and what you wish to achieve(Required)

By submitting this information, you agree to let Boston Medical Group Telemedicine and its partner providers review this data. Health data submitted will not be shared with any other parties unless given direct consent from patient.

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Medical History Content

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About BMG

The Boston Medical Group Telemedicine is a Men’s Health online network dedicated to research and treatment for Erectile Dysfunction and Premature Ejaculation.
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Corporate Office

Boston Medical Group Telemedicine
3152 Red Hill Ave. Ste. #280
Costa Mesa, CA 92626

Latest Blog

Navigating Insurance for ED Injections Costs, Coverage, and Alternatives

Navigating Insurance for ED Injections: Costs, Coverage, and Alternatives

by Boston Medical Group, April 28, 2025

Erectile dysfunction (ED) is more than just a … Read More > about Navigating Insurance for ED Injections: Costs, Coverage, and Alternatives

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