• PATIENT ASSESSMENT FORM - ERECTILE DYSFUNCTION

  • Format: (0000) 000-000.

  • Your symptoms

  • Do you sometimes or always have difficulty getting or keeping an erection? (erectile dysfunction/ED)*
  • Have you had this problem for more than a year?*

  • Your health

  • Have you been advised by a doctor to avoid vigorous exercise?*
  • Would you have difficulty walking fast for 5 minutes?*
  • Do you feel thirsty all the time or need to drink fluids all the time?*
  • Are you currently depressed and NOT seeing a GP about it?*

  • Your medical history - do you have

  • Allergy or adverse reaction to previous ED treatment?*
  • Heart disease including history of heart attack or angina (chest pain when exercising)?*
  • Previous stroke or mini stroke (transient ischaemic attack)?*
  • History of loss of sight due to poor circulation?*
  • The inherited eye disease retinitis pigmentosa (rare)?*
  • Kidney or liver disease?*
  • Any deformity of the penis (e.g. Peryonie's Disease)?*
  • Sickle cell disease or leukaemia or multiple myeloma?*
  • Tendency to bleed excessively (e.g. Haemophilia)?*
  • Stomach ulcers (also known as peptic/gastric ulcer)?*

  • Your medication

  • Are you on any medication?*

  • Confirmation

  • Confirm all questions are answered correctly*

  • Choosing your treatment

    dearPHARMACIST will help you chose a suitable medication and recommend a starting dose. We will contact you to book an appointment.
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