RAF - ED

Erectile Dysfunction - Risk Assessment Form
Patient Information
Patient Name*

First NameLast Name
Date of Birth*

DayMonthYear
Address*

First Line of Address

Street Address 2

CityCountry

Postcode
Email*
Please check your email address is correct
Phone Number*
YesNo
YesNo
Please specify*
YesNo
Please specify*
YesNo
Please specify*
Do you have a medical history of the following: heart disease, heart failure, heart attack, arrhythmias (heart rhythm problems), angina (chest pain during exertion), stroke, mini stroke (transient ischaemic attack), sight loss due to poor circulation, inherited eye disease –retinitis pigmentosa, severe kidney or liver disease, deformity of the penis (e.g. Peryonie’s Disease), painful erections, sickle cell disease/leukaemia/multiple myeloma, bleeding conditions (e.g. haemophilia), stomach ulcers (e.g. gastric/peptic ulcer)?*

YesNo
Unfortunately we are unable to supply you with medication for erectile dysfunction, please contact your GP.
YesNo
Please specifiy*
YesNo
Please specify*
YesNo
Unfortunately we are unable to supply you with medication for erectile dysfunction, please contact your GP.
YesNo
Please specify*
YesNo
YesNo
Please specify*
1 Very low2 Low3 Moderate4 High5 Very high
1 Almost never or never2 A few times (much less than half the time)3 Sometimes (about half the time)4 Most times (more than half the time)5 Almost always or always
1 Almost never or never2 A few times (much less than half the time)3 Sometimes (about half the time)4 Most times (more than half the time)5 Almost always or always
1 Extremely difficult2 Very difficult3 Difficult4 Slightly difficult5 Not difficult
1 Almost never or never2 A few times (much less than half the time)3 Sometimes (about half the time)4 Most times (more than half the time)5 Almost always or always
Score
Collection from:

My Private Chemist

Longcroft House

2-8 Victoria Avenue

EC2M 4NS
Unfortunately we are unable to supply you with medication for erectile dysfunction, please contact your GP.
Should be Empty:

Erectile Dysfunction - Risk Assessment Form

Patient Information