Patient Questionnaire

Skip to primary navigation
Skip to main content
Skip to footer

Boston Medical Group Telemedicine

Call Us!
(800) 337-7555

Book a virtual appointment

Call to Refill Your ICP Now 800 337 7555

Erectile Dysfunction
Premature Ejaculation
Weight Loss
- Weight Loss Injections Guide
Treatment Options
About Us
Blog
Contact

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 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 ED or PE. Describe the effectiveness and any side-effects in as much details as possible. 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.

Hidden

Medical History Content

CAPTCHA

Name

This field is for validation purposes and should be left unchanged.

Footer

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.
• • • • • • • • • • • • • • • • • • • • • •

Corporate Office

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

Latest Blog

How Long Does Ozempic Take to Start Working?

by Cliff Goldman, October 2, 2024

Ozempic, a medication originally designed for … Read More > about How Long Does Ozempic Take to Start Working?

Follow Us

Facebook
Twitter
Instagram
Youtube
Linkedin

Sign up for offers

Email*
CAPTCHA
Email
This field is for validation purposes and should be left unchanged.

© 2024 Boston Medical Group Privacy Policy Terms of Use