Erectile Dysfunction

1. About your Health

To help us understand that this treatment is the right option for you, please answer the following questions. If you get stuck or need any help, you can contact us.

We treat Erectile Dysfunction in males. Are you male?

This refers to your biological gender

Yes

Date of Birth

Use the calendar to select your date of birth.

Please add your height (in cms).

Your height is important for the prescribers decision.

Please add your current weight (in kgs).

Please make sure to add your current weight. This may affect the prescriber's decision.

Have you ever been told that you have high or low blood pressure?
This may have been by your GP or another healthcare professional, or by taking your own blood pressure on a home monitor.

Yes

Do you know if your blood pressure is Low, Normal or High? Please write LOW, NORMAL or HIGH

Use the following as a guide:

Low = Under 90/60
Normal = Between 90/60 and 140/90
High = Over 140/90

Do you smoke?

If you do, please write how many cigarettes you smoke per day. Or, if you vape, please tell us about this.

Yes

Do you drink alcohol?

If so, please tell us how many units per day. You can use the following as a guide:

- Pint of beer = 3 units
- A can of beer = 2 units
- A large glass of red wine = 3 units

Yes

Have you been advised to avoid strenuous exercise?
If yes, please provide the reason

Yes

Is walking or running difficult for you?

If so, please provide more information

Yes

Can you walk 3 miles or climb a set of stairs without pain in your chest?

If you cannot, please provide more information

Yes

Do you have any recent or past medical history of note?
If yes, please provide details

Yes

Are you experiencing any of the following health issues?

You've had a heart procedure, a stroke, or a heart attack in the last five years. You have angina, aortic stenosis, heart failure, cardiomyopathy, high blood pressure that is uncontrolled (greater than 160/90), arrhythmia, or severe heart disease. You have suffered low blood pressure, fainting, or feeling dizzy when you stand up after lying down in the past. Diabetes (type I or type 2) or blood sugar levels that are abnormal. Medical diseases that impact the eyes, such as glaucoma or degenerative eye disease, as well as a family history of these conditions. Peyronie's disease is a deformity or angulation of the penis. Sickle cell disease, leukemia, or multiple myeloma are all examples of blood cancers. A disease that causes bleeding

Yes

Do you suffer from any allergies?
If you do, kindly explain them below

Yes

Do you currently take any medication whatsoever?

Please list all your current prescription medication including any medication you buy over the counter.

Yes

Is there a history of medical disorder's within your family?

If so, please provide more information

Yes

Have you ever had any surgery (operations)?

If so, please provide more details

Yes

Are there any other health/medical details you feel we should know?

If so, please provide more information

Yes

2. About your Erectile Dysfunction

To help us understand that this treatment is the right option for you, please answer the following questions. If you get stuck or need any help, you can contact us.

How do you rate your confidence that you could get and keep an erection?

Low

Moderate

High

Very High

Very Low

When you had erections, with sexual stimulation how often were your erections hard enough for penetration (entering your partner)?

No sexual activity

Almost never or never

A few times (much less than half the time)

Sometimes (about half the time)

Most times (much more than half the time)

Almost always or always

During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?

Did not attempt intercourse

Extremely difficult

Difficult

Slightly difficult

Not difficult

When you attempted sexual intercourse how often was it satisfactory for you?

Did not attempt intercourse

Almost never, or never

A few times (much less than half the time)

Sometimes (about half the time)

Most of the time (much more than half of the time)

Almost always, or always

How long have the symptoms of ED been present?

Please specify the number of months

Do you think there could be psychological causes for your problem e.g. anxiety or depression?

If so, please provide more information

Yes

Do you currently take saquinavir / erythromycin / ketoconazole or itraconazole (please double-check any medication bottles/packs that you may have)

Yes

Do you have a hereditary degenerative retinal disorder such as retinitis pigmentosa?

Yes

Do you currently take any HIV medication such as protease inhibitor e.g. ritonavir?

Yes

Do you currently take nitric oxide donors such as amyl nitrate or nitrates in any form such as poppers?

Yes

Do you have any abnormality of the penis eg Peyronie's disease?

Yes

Have you tried any erectile dysfunction medication before?

You can select one or more options

Viagra

Cialis

Levitra

Spedra

I've never used any ED medication before.

Have you had a serious reaction to an ED medicine before?

If yes, please describe the product/reaction.

Yes

3. The Agreement and Consent

Please answer the following questions to help us confirm that you'll follow the guidelines for this medicine.

Do you agree to the following?

- You declare that I have answered the above truthfully
- You will read the patient information leaflet before taking your medication (if prescribed)
- You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment
- You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health
- You understand that this questionnaire is part of a request to the doctor and the final decision will rest with the doctor

Yes

Would you like a free face to face consultation with our Doctor via Skype video?

Yes

Can we share this information with your General practitioner?

Providing us with your physician's address means that you allow us to share this information with him/her for updated medical records if need be. It also allows our clinician to access your medical records if there is a need for that. We advise you share this treatment with your doctor for him/her to update your medical records.

Yes

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