Form

PATIENT ASSESSMENT FORM - ERECTILE DYSFUNCTION
Full Name*
First Name Last Name
E-mail

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number*
- Area Code Phone Number
Birth Date*
Month Day Year
Your symptoms
Do you sometimes or always have difficulty getting or keeping an erection? (erectile dysfunction/ED)*

Yes No
Have you had this problem for more than a year?*

Yes No
Your health
Have you been advised by a doctor to avoid vigorous exercise?*

Yes No
Would you have difficulty walking fast for 5 minutes?*

Yes No
Do you feel thirsty all the time or need to drink fluids all the time?*

Yes No
Are you currently depressed and NOT seeing a GP about it?*

Yes No
Your medical history - do you have
Allergy or adverse reaction to previous ED treatment?*

Yes No
Heart disease including history of heart attack or angina (chest pain when exercising)?*

Yes No
Previous stroke or mini stroke (transient ischaemic attack)?*

Yes No
History of loss of sight due to poor circulation?*

Yes No
The inherited eye disease retinitis pigmentosa (rare)?*

Yes No
Kidney or liver disease?*

Yes No
Any deformity of the penis (e.g. Peryonie's Disease)?*

Yes No
Sickle cell disease or leukaemia or multiple myeloma?*

Yes No
Tendency to bleed excessively (e.g. Haemophilia)?*

Yes No
Stomach ulcers (also known as peptic/gastric ulcer)?*

Yes No
Your medication
Are you on any medication?*

Yes No
If yes, please list all medication you take or use. Include medicines prescribed by your GP, over the counter and any recreational drugs, e.g. poppers (amyl nitrate):
Confirmation
Confirm all questions are answered correctly*

Yes No
Choosing your treatment

The pharmacist will help you chose a suitable medication and recommend a starting dose. We will contact you to book an appointment.
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PATIENT ASSESSMENT FORM - ERECTILE DYSFUNCTION

Your symptoms

Your health

Your medical history - do you have

Your medication

Confirmation

Choosing your treatment