Erectile Dysfunction - Consultation

Full name

Date of birth (DD/MM/YYYY)

Biological sex at birth

Which best describes your symptoms?

How long have you been experiencing these difficulties?

Do you still experience morning or night-time erections?

Yes

Have you used erectile dysfunction medication before?

Yes

Do you take any nitrate medication or nitric oxide donors?

Yes

Have you ever been advised not to take ED medication by a doctor?

Yes

Do you take medication for blood pressure, prostate symptoms, heart problems, or HIV?

Yes

Have you ever been diagnosed with:

Have you had any of the following within the last 6 months?

Has a doctor ever advised you to avoid sexual activity due to a heart condition?

Yes

Do you know your most recent blood pressure reading?

Do you have any of the following?

Do you have any penile conditions or blood disorders such as:

Have you ever experienced sudden vision loss or been diagnosed with a serious eye condition such as NAION or retinitis pigmentosa?

Yes

Do you have any medication allergies?

Do any of the following apply?

Do you believe stress, anxiety, low mood or relationship difficulties may be contributing to your symptoms?

Yes

Do you feel safe in your current relationship?

Yes

Do you have a preferred treatment?

I confirm that:

I understand ED medication must not be taken with nitrates.
I will not take more than one ED medication at the same time.
I understand the maximum single dose is Sildenafil 100mg or Tadalafil 20mg.
I understand ED can sometimes indicate underlying cardiovascular disease and I may be advised to see my GP.
The information I have provided is accurate and complete.
I understand treatment may be refused if it is not clinically appropriate.

I confirm that I understand and agree to the above

I agree to seek urgent medical attention if I experience:

I confirm that I understand and agree to the above

To support continuity of care, we request your GP details.

Yes

Is there anything else our prescribers should know about your health or circumstances?