Patient Form

SCHEDULE AN APPOINTMENT

Talk to the Experts in Men’s Sexual Health
At Charleston Men’s Clinic, your care is our priority. If you have any questions about scheduling an appointment, your results, or other questions, please contact our friendly and knowledgeable staff.

how did you hear about us?

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medical questionnaire (please check each that applies)

medical history

high blood pressurehigh cholesteroldiabetesheart diseasemultiple sclerosisepilepsyhepatitisbowel problemsother
prostate cancerlow testosteronesleep apneasickle cell diseaseheart attackblocked arterycoronary heart diseasestroke/tia
parkinson's diseaseliver diseasekidney diseaseenlarged prostate (bph)peyronie's diseaseHIV infection/aidsbleeding disorderstomach problems

allergies (have you ever had an allergic reaction to any medications?)

yesno

personal habits: (please check each that applies)

do you drink alcohol ?

nonot anymorerarelysociallyweekendsregularly/daily

smoking ?

nevernot anymoreyes
quit years ago
smoked packs/days for
years

recreational drug: (marijuana, cocaine, meth, etc ?)

nonot anymoreyes
quit years ago
drug and amount:

relationship status: (please check each that applies)

currently marriednot married, but in a committed relationship
currently married year:
not married, but in a committed relationship, how long
datingdivorcednot dating or sexually activewidowedcurrently single
if divorced (how many times)
if widowed (how long ago)
if currently single never married

level of physical activity: (please check each that applies)

totally inactivesedentarylightmoderateheavy

family history: (please check each that applies)

diabetes: yesno
heart disease: yesno
prostate cancer: yesno
sickle cell: yesno

please provide your current physician:

primary care physician

name:
office/city:

urologist

name:
office/city:

cardiologist

name:
office/city:

endocrinologist

name:
office/city:
i authorize Charleston men's clinic to share information and test results with my primary physician and / or specialist yesno
signature:
date:

main complaint(s) today:

difficulties in getting an erection: yesno
difficulties in maintaining an erection: yesno
early (premature) ejaculation: yesno
decreased libido (low sex drive): yesno

treatment tried for erectile dysfunction:

medication:

viagra (sildenafil)cialis (tadalafil)daily cialislevitra (vardenafil)caverjectmusetrimixpenile pump/ringpenis ring

adam (androgen deficiency in the aging male) questionnaire:

Map & Directions

Conveniently located in Mount Pleasant serving the Greater Charleston area.

Call today to schedule a consultation guaranteed to provide you with answers and effective options.

READ REAL REVIEWS. THE RESULTS DO THE TALKING.