PDI SURVEY

This survey is a very important project of PDI and it should be important to you, too. The purpose of these survey questions is to search for possible contributing or predisposing factors, or related conditions that might prove useful in advancing the understanding PD. Your responses will be useful in developing a profile associated or dependent conditions that might be related to PD in some way that has yet to be determined.

Our intention is to collect information from as many men with PD as possible, compare their answers, and develop clinical profiles to explore for indicators in the disease process. In so doing we hope to find a common trend or similarity that might help us to understand PD better. Filling out this  survey could be a good way to help others and to help yourself.

Please take a few moments to answer the questions listed below.  We really appreciate your help by providing us with this information. 

Please choose one answer for the multiple choice questions. For all the other questions, please answer by clicking on either “Yes” or “No”.

1.  Age (years)	Under  25 26-35 36-45 46-55 56-65 Over 65
2.  How long have you had PD?	> 6 months 7-12 months 13-18 months 19-24 months 2-3 years 4-6 years 7 years +
3.  Does your PD scar(s) seem to change in any way from time to time?	Yes No
4.  Does the SIZE of your PD scar seem to change - sometimes bigger, sometimes smaller?	Yes No
5. If you answered "yes" to question 4, how much does the scar USUALLY change in SIZE (either bigger or smaller)?	Not sure 1/8" - 1/4" 1/4" - 1/2" 1/2" - 3/4" 3/4" - 1" Varies
6. If you answered "yes" to question 4, how often does the scar USUALLY change in SIZE	Once or twice 3-5 times Once or twice / mo. 3-5 times / mo. Every week Varies
7. Does the HARDNESS or DENSITY of your PD scar seem to change - sometimes the scar seems firmer, and sometimes softer?	Yes No
8. If you answered "yes" to question 7, how much does the scar USUALLY change in HARDNESS or DENSITY?	Not sure Very little Moderate Significant Major Varies
9. If you answered "yes" to question 4, how often does the scar USUALLY change in HARDNESS or DENSITY?	Once or twice 3-5 times Once or twice / mo. 3-5 times / mo. Every week Varies
10. Does your PD scar(s) ever seem to disappear for a while (you can't really locate it), and then at a later time it reappears in about the same location?	Yes No
11. If you answered "yes" to question 10, how often does the scar disappear and reappear?	Once or twice 3-5 times Once or twice / mo. 3-5 times / mo. Every week Varies
12. Do you have pain with your PD; does your penis hurt anywhere?	Yes No
13. If you answered "yes" to question 12, how much pain do you USUALLY experience?	Not sure Very little Moderate Significant Major Varies
14. If you answered "yes" to question 12, how often do you USUALLY experience pain?	Once or twice A few hours / mo. A few hours / week A few hours / day Most of the time Constant Varies
15. If you answered "yes" to question 12, is there USUALLY a pattern to your pain?	Never a pattern Not now No pattern During an erection After sexual activity Constant pain
16.  Do you sit on average less than 4 hours a day?	Yes No
17.  Do you sit on average between 4-8 hours a day?	Yes No
18.  Do you sit on average more than 8 hours a day?	Yes No
19.  Are you less physically active than you were 5-10 years ago; have you been getting less general exercise and activity in the last 5-10 years than you previously were accustomed?	Yes No
20. Compared to 5-10 years ago, are generally out of shape?	Yes No
21.  Compared to 5-10 years ago, do you feel a general state of weakness and fatigue that previously did not bother you?	Yes No
22.  Compared to 5-10 years ago, are your hips and low back more stiff and achy, (difficulty getting out of a chair, not able to straighten up as soon as you get out of bed because of specific tightness in the hips and low back)?	Yes No
23.  Do you have a history of frequent low back pain?	Yes No
24. As a child was it difficult for you to bend over to touch your toes?	Yes No
25. Was your sexual activity in decline even before the onset of your PD?	Yes No
26. Have you ever had an inguinal (groin) hernia, on one or both sides?	Yes No
27. Have you ever had surgery to repair an inguinal (groin) hernia?	Yes No
28. Have you had a vasectomy?	Yes No
29. Do you have varicose veins in one or both legs?	Yes No
30. Do you have cold hands and feet when other people are not cold like you are?	Yes No
31. Are your feet often colder than your hands?	Yes No
32. Compared to 5-10 years ago, are there a lot of foods that bother you now?	Yes No
33. Are you a vegetarian?	Yes No
34. Do you regularly have digestive problems such as pain, bloating, gas, or diarrhea?	Yes No
35. Do you have a problem with anal leakage?	Yes No
36. Do you have an “irritable gut”; right after eating you sometimes have urgent and watery diarrhea?	Yes No
37. Do you have vertical ridges on your fingernails?	Yes No
38. Do you have more than three white spots and flecks on your fingernails; do you have more white flecks and spots on your fingernails than most people?	Yes No
39. Do you drink very little water; can go a long time and not get thirsty?	Yes No
40. Do you have tinnitus (ringing, buzzing, humming or funny noises in your ears)?	Yes No
41. Did you get gray hair early in life; went gray sooner than others your age?	Yes No
42. Do you have Dupuytren's contraction (drawing up of the tissue of the palm, resulting in flexion of one or more fingers toward the palm)?	Yes No
43. Do you have diabetes?	Yes No
44. Do you have epilepsy?	Yes No
45. Do you have hemorrhoids?	Yes No
46. Do you get more than one cold sore a year?	Yes No
47. Do you notice your urine turns a reddish-brown after you work or exercise for a prolonged time?	Yes No
48. Have you ever had a surgical or medical diagnostic procedure in which a medical device or instrument, or any other non-medical object, was placed up your urethra (urinary passage in the penis)?	Yes No
Email address

"You are being asked for your email address so that PDI can communicate with you if additional information is needed concerning a particular answer you have given. This will only be done if this information is important in a developing statistical pattern of answers."

Again, thanks for the benefit of your information and time.

Privacy Statement
Your answers are always strictly confidential and will absolutely not be used in any manner beyond the stated purpose. No names, answers or information will ever be connected back to you, shared or given to others. This information does not cycle beyond  PDI. The answers you provide in the surveys are collected, reviewed and cataloged by PDI; this information is stored outside of this section of the website without any name, origin or information identifying a source for any particular answer.

For additional information please review our Privacy Policy.
 

Peyronie's Disease Institute
504 North Plum Grove Road
Palatine, IL 60067
Toll Free (877) 878-8188

Date last modified:  December 20, 2007

info@peyronies-disease-help.com