Rxpress

Erectile Dysfunction (ED) Risk Assessment & Initial Consultation

Title:
—Please choose an option—MrMrsMissMsOther

Date of Birth (DD/MM/YY):

Age:

Home Address:

Name:

Surname:

Name & Address of GP (optional):

Email:

Telephone:

Would you like your GP to be informed of this consultation?
YesNo

Please answer the following questions

Have you had a serious reaction to an ED medicine before?
YesNo

If yes, please describe the product/reaction:

Do you have higher or lower than normal blood pressure?
YesNo

If yes, please provide details:

Have you been advised to avoid strenuous exercise?
YesNo

If yes, please provide the reason:

Do you have any of the following medical history?
Heart diseaseHeart failureHeart attackArrhythmiasAnginaStrokeMini strokeSight loss (circulation-related)Retinitis pigmentosaKidney/liver diseasePenile deformityPainful erectionsSickle cell diseaseLeukaemiaMultiple myelomaBleeding conditionsStomach ulcers

Is walking or running difficult for you?
YesNo

Do you have symptoms of depression and have not seen a GP?
YesNo

If yes, please provide details:

Do you have difficulty in getting or maintaining an erection?
YesNo

Do you have any recent or past medical history of note?
YesNo

If yes, please provide details:

Are you aware ED can mask underlying medical conditions, and that it is recommended to consult your doctor?
YesNo

Do you take any current or repeat medicines?
YesNo

List all current prescription and over-the-counter medications:

Please write below any further relevant information (e.g. conditions):

Erectile Dysfunction Severity Indicator (Over the Past 6 Months)

1. Confidence in getting and keeping an erection:
Low – 1Very Low – 2Moderate – 3High – 4Very High – 5

2. Erections hard enough for penetration:
Almost never or never – 1A few times – 2Sometimes – 3Most times – 4Almost always or always – 5

3. Ability to maintain erection after penetration:
Almost never or never – 1A few times – 2Sometimes – 3Most times – 4Almost always or always – 5

4. Difficulty maintaining erection to completion:
Very difficult – 1Difficult – 2Slightly difficult – 3Not difficult – 4

5. Frequency of satisfactory sexual intercourse:
Almost never or never – 1A few times – 2Sometimes – 3Most times – 4Almost always or always – 5

TOTAL SCORE:

The Sexual Health Inventory for Men classifies ED severity as:

• 1-7: Severe ED (Excluded)

• 8-11: Moderate ED (Included)

• 12-16: Mild to Moderate ED (Included)

• 17-21: Mild ED (Excluded)

Do we have permission to access your medical records?
YesNo