Erectile Dysfunction Patient Risk Assessment

Erectile Dysfunction Patient Risk Assessment and Consent Form
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Title
Name

First NameLast Name
Telephone number
Date of Birth

DayMonthYear
Type a question
Address (Line 1)
Address (Line 2)
NHS Number (If known)
GP Name
GP Address
GP Telephone (If known)

Patient's personal details

Rows	Yes	No	Add extra details if required.
Do you have any recent or past medical history of note?
Do you take any current or repeat medicines?
Do you have higher or lower than normal blood pressure?
Have you had a serious reaction to an ED medicine before?
Do you have a medical history of the following: heart disease, heart attack, 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)?

Current Health

Rows	Yes	No	Add extra details if required.
Have you been advised to avoid strenuous exercise?
Is walking or running difficult for you?
Do you have symptoms of depression and have not seen a GP?

What symptoms are you experiencing?

Rows	Yes	No	Add extra details if required.
Do you have difficulty in getting or maintaining an erection?

GP appointment...

Rows	Yes	No	Add extra details if required.
Erectile dysfunction can sometimes mask underlying medical conditions; it is recommended that you agree to consult your doctor about this...

Write below any further information which may be relevant e.g. medicines taking, conditions suffered, concerns...
Should be Empty: