Peyronie’s Disease Questionnaire Patient InformationName* First Last Date of Birth* Email* Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneRx Number*You will need your prescription number before filling out survey and qualifying for discount creditMonths of Treatment*Please select 0 if you are just starting treatment, 3 if you have completed 3 months treatment and 6 if you have completed 6 months treatment036Privacy Agreement* I authorize Hybrid Medical to use my non-personally identifiable health information provided below for research purposes. QuestionnaireFor research purposes, this survey is intended to help measure patient progress at ongoing stages of H100™ use. Please mark ONE answer per question. Thank you.Q1: Is this the first time you are you are using H100?Answer yes even if you have begun the first month treatment with H100.YesNoQ1b: How many months has it been since Peyronie's disease onset?Q2. Thinking about the LAST TIME you had an erection, how bothered were you by any pain or discomfort you may have felt in your erect penis?*Please answer for the LAST TIME YOU HAD AN ERECTIONNot at all botheredA little bit botheredModerately botheredVery botheredExtremely botheredDid not feel any pain or discomfortQ3. Thinking about the LAST TIME you looked at your erect penis, how bothered were you by the way your penis looked?*Please answer for the LAST TIME YOU HAD AN ERECTIONNot at all botheredA little bit botheredModerately botheredVery botheredExtremely botheredQ4. Does your Peyronie's disease make having vaginal intercourse difficult or impossible?*YesNoQ4b. Thinking about the LAST TIME you had or tried to have vaginal intercourse, how bothered were you by your Peyronie's disease?*Not at all botheredA little bit botheredModerately botheredVery botheredExtremely botheredQ5. Are you having vaginal intercourse LESS OFTEN than you used to due to your Peyronie's disease?*YesNoQ5b. How bothered are YOU with having vaginal intercourse less often?*Not at all botheredA little bit botheredModerately botheredVery botheredExtremely botheredQ6: Estimate your degree of penile curvature in degrees*Please enter a value between 0 and 180.