ALPHA MED GROUP FLA

Men’s Health Intake Form

New Patient Forms are available online for your appointment with Alpha Med Group Health, serving patients in the Tampa Bay area. If you have any questions about forms or to schedule your new patient consultation, give us a call today!

  727-977-8200

• NAME *
• DOB *
• ADDRESS *
• CITY *
• STATE
• ZIP CODE *
• EMAIL *
• PHONE
• EMPLOYMENT
• EMPLOYER
• EMERGENCY CONTACT
• RELATION PARENT SPOUSE OTHER
• EMERGENCY CONTACT PHONE # * Enter Area Code & Telephone Number
• ALLERGIES To Medications Only | If None, Leave Blank
• WHEN DID ED START? * 1 Month Ago? 1 Year Ago? 10 Years Ago?
• WHAT ED DRUGS HAVE YOU TRIED? Viagra Cialis Levitra Trimix Other
• DID ED DRUGS EVER WORK?
• ANY ED DRUG SIDE EFFECTS?
• ErectionshowDISABLEDoften Daily
• DIAGNOSED MEDICAL CONDITIONS
• WHAT MEDICATION DO YOU TAKE?
• HAVE YOU HAD ANY SURGERIES?
• INDICATE YOUR CURRENT STATUS Single Married Dating Divorced Widowed
• DO YOU SMIKE CIGARETS Yes No
• HOW MANY TIMES WEEKLY?
• DO YOU DRINK MORE THAN 2 ALCOHOLIC BEVERAGES DAILY? Yes No
• ANY HISTORY OF EXPLICIT DRUG USE? Yes No
• How confident are you that you could achieve a full rigid erection? 1 – Never / Almost-never 2 – Rarely 3 – Some times 4 – Frequently 5 – Always

• IIEF-5 Impotence Score

  IN THE PAST 6 MONTHS…
• How confident are you that it will sustain long enough for penetration? 1 – Never / Almost never Rarely Sometimes Frequently Always
• Does your erection maintain firm enough to penetrate? 1 – Never / Almost never 2 – Rarely 3 – Sometimes 4 – Frequently 5 – Always
• Can you stay erect until the completion of intercourse? 1 – Extremely difficult Difficult Neutral Simple Easy
• Satisfaction after intercourse 1 – Never / Almost never 2 – Rarely 3 -Some of the time 4 -Usually 5 -Always
• Send
• Should be Empty:

Now create your own Jotform – It’s free! Create your own Jotform

New Patient Intake Process

Step 1

Schedule your initial consultation with Alpha Med Group by calling us at
727-977-8200

Step 2

Complete your new patient intake forms online today, or arrive 10 minutes early for your initial consultation.

Step 3

Enjoy the highest level of patient care at Alpha Med Group, located at
2454 McMullen Booth Rd Ste 720 Clearwater, FL 33759

About Alpha Med Group

 

Take the first step towards better health today by scheduling your FREE CONSULTATION with our team of licensed and highly trained men’s health professionals at Alpha Med Group in Clearwater; proudly serving men of the greater Tampa Bay, St. Petersberg, and Largo area since 2020.

 

Alpha patients achieve optimal men’s health and vitality by participating in our advanced individualized approaches to proactive men’s health. Alpha Med Group can help men suffering from Erectile Dysfunction with easy access to our comprehensive men’s health services for a vast range of men’s health needs- effective at any age or condition. Our world class team of men’s health professionals at Alpha Med Group in Clearwater and Nationally can help you to achieve your wellness goals quickly, safely, and effectively. What are you waiting for? We can help you now.

 

Contact us today at 727-977-8200 or visit online at AlphaMedGroupFla.com to learn more about our men’s health services.