Erectile Dysfunction assessment | Pharma Aesthetics

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Erectile Dysfunction Treatment Medical Questionnaire

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Medical Questionnaire

Patient Notice: This Questionnaire forms the basis of your Erectile Dysfunction Treatment consultation today. We need you to be honest with your answers including any current medications you are on. This allows our doctors to prescribe medication that helps you and offer accurate advice. We expect you to read the medical information before selecting your treatment.

Your Symptoms

Do you find it difficult to achieve or maintain an erection sufficient for sexual activity?*

Yes

No

Please provide more information below.*

Have you noticed a decrease in sexual desire or libido recently?*

Yes

No

Please provide more information below.*

Is this issue affecting your sexual relationships or causing you distress?*

Yes

No

Please provide more information below.*

Have you experienced erectile dysfunction consistently over the past few months?*

Yes

No

Please provide more information below.*

Does the problem occur regardless of the type of sexual activity or the time of day?*

Yes

No

Please provide more information below.*

Health

Are you currently taking any medications that might contribute to erectile dysfunction, such as antidepressants, blood pressure medications, or antiandrogens?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Do you have any underlying health conditions, such as diabetes, cardiovascular disease, or hypertension, that could be linked to ED?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Have you been diagnosed with a psychological condition, such as depression or anxiety, that could be affecting your sexual function?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Are you currently using or have you recently used any recreational drugs or excessive alcohol, which can affect erectile function?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Have you previously sought treatment for erectile dysfunction, and if so, what treatments were tried?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Acknowledgements

Please Confirm

I understand if I start to experience any symptoms that seem out of the ordinary, I must see a GP.

These questions aim to provide a thorough overview of the patient's symptoms and health, crucial for safely prescribing effective treatments for erectile dysfunction.

Consent

We strongly advise that you inform your GP of any treatment you receive, Would you like us to inform them on your behalf?*

Yes

No

Your GP Address Details

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Your Details

Name*

First Last

Phone*

Date of Birth*

Day

Month

Year

Your Home Address*

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Please Confirm

Confirmation*

I Confirm

• I confirm I am over 18 years old
• The medicine is ordered for myself
• I will read the patient information leaflet supplied with the medicine and specifically the side effects and dosages
• I take responsibility to inform my own regular doctor of this online consultation or any changes in my circumstances.
• I agree to the Pharma Aesthetics Terms and Conditions.

If treatment is not suitable, you will be refunded and signposted to another point of care. The decision about treatment is for both the patient and the prescriber to consider, however, the final decision will always lie with the prescriber.

Email

This field is for validation purposes and should be left unchanged.

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16 Broadway, Rainham, Essex, RM13 9YW
01708 608860
info@pharma-aesthetics.co.uk

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