Pre-consultation: Erectile Dysfunction

First name *

Last name *

Email *

Phone *

Date of birth *

How do you rate your confidence that you could get and keep an erection? *

IIEF-5 scoring: 5-7 severe ED, 8-11 moderate, 12-16 mild-moderate, 17-21 mild, 22-25 no ED

Very low

Low

Moderate

High

Very high

When you had erections with sexual stimulation, how often were your erections hard enough for penetration? *

Almost never or never

A few times

Sometimes

Most times

Almost always or always

During sexual intercourse, how often were you able to maintain your erection after you had penetrated your partner? *

Almost never or never

A few times

Sometimes

Most times

Almost always or always

During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse? *

Extremely difficult

Very difficult

Difficult

Slightly difficult

Not difficult

When you attempted sexual intercourse, how often was it satisfactory for you? *

Almost never or never

A few times

Sometimes

Most times

Almost always or always

How long have you experienced erectile difficulties? *

Less than 1 month

1-6 months

6-12 months

1-2 years

More than 2 years

How did the erectile difficulties start? *

Gradual - getting slowly worse

Sudden - started abruptly

Variable - comes and goes

What is the pattern of your erectile difficulties? *

Consistent - happens every time

Situational - with certain partners or situations

Variable - sometimes OK sometimes not

Do you get morning erections? *

Morning erections suggest adequate blood flow - their presence points to psychological rather than physical causes

Regular - most mornings

Occasional

Rare

None

How is your ejaculation? *

Normal

Premature

Delayed

Difficulty reaching orgasm

How would you describe your libido (sex drive)? *

Normal

Slightly reduced

Significantly reduced

Absent

Are you currently in a sexual relationship? *

Yes

No

It's complicated

Do you experience performance anxiety during sex? *

No

Sometimes

Frequently - major factor

Always - can't relax during sex

How would you rate your current stress level? *

Low

Moderate

High

Very high

Over the last 2 weeks, have you felt down, depressed or hopeless? *

Depression can contribute to ED

Not at all

Several days

More than half the days

Nearly every day

How much anxiety do you have specifically about sexual performance? *

None

Mild

Moderate

Severe - avoiding sex because of it

How often do you use pornography? *

Heavy pornography use can contribute to ED in some men - this is confidential

None

Occasional

Regular

Heavy

Do you smoke? *

ED is often the first sign of cardiovascular disease - these questions help assess your overall vascular health

No

Yes

Do you have diabetes? *

No

Yes

Do you have high blood pressure? *

No

Yes

Do you have high cholesterol? *

No

Yes

Is there a family history of heart disease in a male relative under age 55? *

No

Yes

Do you experience chest pain or tightness on exertion? *

RED FLAG - requires urgent cardiac assessment

No

Yes

Do you experience shortness of breath on exertion? *

No

Yes

What is your weight and height (or BMI if known)?

How would you describe your exercise level? *

Sedentary

Light (1-2 days per week)

Moderate (3-4 days per week)

Active (5+ days per week)

Are you currently taking any of these medications that can cause ED? *

SSRIs/antidepressants

Beta-blockers

Blood pressure tablets

Finasteride (for hair loss or prostate)

Antipsychotics

Opioid painkillers

Antihistamines

None of these

Are you taking any recreational drugs? (cannabis, cocaine, MDMA, poppers/amyl nitrite, anabolic steroids, other)

Do you take nitrates for chest pain? (GTN spray, isosorbide mononitrate) *

ABSOLUTE CONTRAINDICATION - PDE5 inhibitors (Viagra, Cialis) CANNOT be used with nitrates - potentially fatal drop in blood pressure

No

Yes

Not sure

Do you use poppers (amyl nitrite)? *

Also a nitrate - same contraindication with PDE5 inhibitors

No

Yes

Have you tried any ED treatment before? *

No

Yes

Please list all medications you're currently taking (including over-the-counter, supplements, herbal remedies) *

What are you hoping for from this consultation? *

First-time ED treatment

Try a different medication

Dose adjustment of current medication

Investigate underlying cause

Psychological support

General advice and reassurance

Is there anything else you'd like us to know?

Here's what you've told us. Have a quick check, then hit send - this means your consultation can focus on what actually matters to you.

Your details

Name

Email

Phone

Date of birth

Erectile Function Assessment (IIEF-5)

How do you rate your confidence that you could get and keep an erection? -

When you had erections with sexual stimulation, how often were your erections hard enough for penetration? -

During sexual intercourse, how often were you able to maintain your erection after you had penetrated your partner? -

During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse? -

When you attempted sexual intercourse, how often was it satisfactory for you? -

Symptom Characterisation

How long have you experienced erectile difficulties? -

How did the erectile difficulties start? -

What is the pattern of your erectile difficulties? -

Do you get morning erections? -

How is your ejaculation? -

How would you describe your libido (sex drive)? -

Relationship & Psychological Factors

Are you currently in a sexual relationship? -

Do you experience performance anxiety during sex? -

How would you rate your current stress level? -

Over the last 2 weeks, have you felt down, depressed or hopeless? -

How much anxiety do you have specifically about sexual performance? -

How often do you use pornography? -

Cardiovascular Risk Assessment

Do you smoke? -

Do you have diabetes? -

Do you have high blood pressure? -

Do you have high cholesterol? -

Is there a family history of heart disease in a male relative under age 55? -

Do you experience chest pain or tightness on exertion? -

Do you experience shortness of breath on exertion? -

What is your weight and height (or BMI if known)? -

How would you describe your exercise level? -

Medications That Can Cause ED

Are you currently taking any of these medications that can cause ED? -

Are you taking any recreational drugs? (cannabis, cocaine, MDMA, poppers/amyl nitrite, anabolic steroids, other) -

Nitrate & Drug Interaction Safety (CRITICAL)

Do you take nitrates for chest pain? (GTN spray, isosorbide mononitrate) -

Do you use poppers (amyl nitrite)? -

Previous ED Treatment

Have you tried any ED treatment before? -

All Current Medications

Please list all medications you're currently taking (including over-the-counter, supplements, herbal remedies) -

Your Goals

What are you hoping for from this consultation? -

Is there anything else you'd like us to know? -

Anything else for your doctor?