PATIENT INTAKE FORM - Heads Up Las Vegas

Name *

First

Last

Date / Time

Address

Address Line 1

City

State

Zip Code

Cellular Phone

Home Phone

age

Date of Birth

Email *

Employer

Occupation

Emergency Contact

Number

Primary Physician

Last Physical

How Did You Hear About Us?

Station/Program/Etc

What Is Your Primart Concern?

How Long Have You Had Difficulty?

Difficulty in Getting an Erection

Yes
No

Premature Ejaculation

Yes
No

Difficulty in Maintaining an Erection

Yes
No

Can you Ejaculate

Yes
No

Erections too soft for entry

Yes
No

Achieve Orgasm

Yes
No

Erection in the:

Morning
With Arousal
Only With Meds
None

HAVE YOU EVER USED ANY MEDICATIONS FOR ERECTILE DYSFUNCTION?

Viagra: Never/Good Result/ Poor Result/ Side Effects/ Last Used

Cialis: Never/Good Result/ Poor Result/ Side Effects/ Last Used

Livitra: Never/Good Result/ Poor Result/ Side Effects/ Last Used

Muse: Never/Good Result/ Poor Result/ Side Effects/ Last Used

Injections: Never/Good Result/ Poor Result/ Side Effects/ Last Used

Testosterone: Never/Good Result/ Poor Result/ Side Effects/ Last Used

Other/OTC: Never/Good Result/ Poor Result/ Side Effects/ Last Used

Prostate Cancer

Yes
No

Liver Disease

Yes
No

Large Prostate

Yes
No

Hepatitis

Yes
No

Uro-Genital Problems

Yes
No

Vascular Disease

Yes
No

Peyronie's (curved Penis)

Yes
No

Major Depression

Yes
No

STD

Yes
No

Bleeding Disorder

Yes
No

HIV Infection/ AIDS

Yes
No

Kidney Disease

Yes
No

Cancer

Yes
No

Sickle Cell Disease

Yes
No

Heart Disease

Yes
No

Multiple Sclerosis

Yes
No

Stroke

Yes
No

Pankinson's Disease

Yes
No

High Blood Pressure

Yes
No

High Cholesterol

Yes
No

Diabetes

Yes
No

Bowel Problems

Yes
No

Smoking

Yes
No

Alcohol/Drugs

Yes
No

Medical Allergies?

Current Medications

The IIEF-5 Questionnaire(SHIM) Circle the Best Response Without Any ED Medications

How do you rate your confidence that you could get and keep an erection?

Selected Value: 0

How often are your erections hard enoughfor entry?

Selected Value: 0

During sexual intercourse how often are you able to maintain your erection after you have entered your partner?

Selected Value: 0

During sexual intercourse,how difficult is it to maintain your erection to completion

Selected Value: 0

When you attempt sexual Intercourse how often is it satisfactory for you?

Selected Value: 0

Shim Score

1-7 =Severe 8-11 = Moderate 12-16= Mild Moderate 17-21=Mild >22= No ED

HIPAA PRIVACY NOTICE This form is intended for the use and/or disclosure of Protected Health Information (PHI) when providing or seeking treatment, payment, and healthcare operations. 1. This Privacy Notice contains a thorough and complete description of the uses and/or disclosures of my protected health information ("PHI") which are necessary to provide me with treatment, and which are also necessary for the Practice to obtain payment for that treatment and to perform other healthcare operations. I have been informed that, upon my request, the privacy notice will be made available to me. Prior to signing this Agreement, the Practice advised me of my right to obtain a copy of the Privacy notice and has encouraged me to read it in its entirety, in accordance with applicable law. 2. To protect your privacy and to remain in compliance with applicable law, the Practice reserves the right to change the practices depicted in its Privacy Notice. 3. I am aware that the Practice's "Notice of Privacy Practices" is displayed on the clinic website and that I am free to request a copy of the same at any time. 4. This Notice of Privacy Practices contains my rights, as well as the duties and obligations of this office as it relates to my protected health information.

I can climb two flights of stairs without chest pain or extreme shortness of breath?

Yes
No

I understand that the physician reviews my medical history and does not prescribe Acoustic Shock Wave Therapy?

Yes
No

I have read and understand this notice in its entirety and agree that any questions I may have had have been answered to my full and complete satisfaction and understanding.

Name of Individual (Printed) *

First

Last