Erectile Dysfunction Risk Assessment Form
About You
Name
*
First Name
Last Name
Gender
*
Male
Female
Date of birth
*
-
Month
-
Day
Year
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
NHS Number (if known)
*
Email
*
example@example.com
Phone Number
*
Name of General Practice
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
About your health
Do you have difficulty in getting or maintaining an erection?
*
Yes
No
Do you have higher or lower than normal blood pressure?
*
Yes
No
Have you had a serious reaction to an ED medicine before?
*
Yes
No
If Yes, may you please explain
Have you been advised to avoid strenuous exercise?
*
Yes
No
Is walking or running difficult for you?
*
Yes
No
If Yes, may you please explain
Erectile dysfunction can sometimes mask underlying medical conditions; it is recommended that you consider consulting your doctor about this?
*
Yes
No
Do you take any current or repeat medicines?
*
Yes
No
If Yes, may you please explain
Do you have a past medical history of any of the following (please tick any that may apply)
*
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)?
Submit
Should be Empty: