Erectile dysfunction consultation

What was your sex at birth? Male Female

Date of birth

Day

Month

Year

Do you have any problems getting an erection, or keeping one as long as your want to? Yes No

Can you tell us why you'd like to use erectile dysfunction medication?

Have you used any erectile dysfunction medication before? Yes No

Did you have any side effects? Yes No

What were the side effects?

What was the medication and the dose you were on when you had them?

Have you ever suffered from a curvature of the penis? Yes No

Do you know what caused this?

Have you ever had a painful erection? Yes No

Please select the cause

Peyronie's disease Scarring or bend of the penis Trauma or injury to the penis Being unable to retract the foreskin (phimosis) Having the foreskin stuck behind the head/glans (paraphimosis) Something else Not sure

Please describe what caused your painful erection

Please describe what happened

Have you used any erectile dysfunction medications since having a painful erection? Yes No

Did you have any further problems with painful erections then? Yes No

In the last 6 months, have you been told by a doctor to avoid physical or sexual activity? Yes No

Why did the doctor tell you to avoid these activities?

Have you been told that you can start to do these activities again? Yes No

Have you ever had a stroke? Yes No

When did you have a stroke?

What treatment did you have?

Have you been diagnosed by a doctor as suffering from any of the following conditions?

High blood pressure Dyslipidemia No, neither of these

Please confirm the date you were diagnosed with high blood pressure

Day

Month

Year

Please confirm the date you were diagnosed with dyslipidemia

Day

Month

Year

Do you have any blood conditions like myeloma, leukaemia, sickle cell disease or haemophilia? Yes No

Please describe the condition

Do you still have this? If not, when did you have this?

What treatment have you had for this?

Do you often get breathless or have chest pain when you do light exercise, like walking up stairs? Yes No

How often does this happen?

Have you seen a doctor about it? Yes No

When did you see a doctor and were you told why this was happening?

Have you had any tests for it? Yes No

What tests have you had and what were the results?

Please describe what happens

Do you currently have, or are you using treatment for any of the following:

A stomach or duodenal ulcer Non-arteritic ischaemic optic neuropathy (NAION) Retinitis pigmentosa No, none of the above

Do you have:

A stomach ulcer A duodenal ulcer Both

Do you still have an ulcer? Yes No

What treatment have you had?

Are you still using treatment for these? Yes No

When did you have the ulcer(s)?

What treatment have you had?

Are you currently using any other medication, even if you’re not taking it regularly? Or have you finished a course of medication in the last month? Yes No

Please tick all of the relevant medications

Alpha-blockers (for example alfuzosin, prazosin, doxazosin, tamsulosin. These are used to reduce blood pressure or treat prostate problems) GTN spray or tablets (even if you're not using these regularly) Isosorbide medications Blood-thinning medications (for example aspirin, warfarin or heparin) Other medications

Please tell us the name of the medication and what you use it for.

Are you still taking these medications? Yes No

Are you allergic to any medicines or other substances, for example peanuts or soya? Yes No

Please tick all of the allergies that apply to you.

Finasteride Penicillin Peanuts or Soya Lactose Other medications Other substances

Please describe your reaction to lactose and if you can tolerate tablets containing lactose

Please provide more details about your allergies to other medications

Please provide more details about your allergies to other substances

Would you like us to inform your GP of your consultation? Yes No

Order Viagra, Cialis or other erectile dysfunction treatments

Not suitable

This service is only available for males over the age of 18