Erectile Dysfunction

Patient's personal details

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

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Do you take any current or repeat medicines? *

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

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

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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)? *

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Current Health

Have you been advised to avoid strenuous exercise? *

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Is walking or running difficult for you? *

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

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What symptoms are you experiencing?

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

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GP appointment...

Erectile dysfunction can sometimes mask underlying medical conditions; it is recommended that you agree to consult your doctor about this... *

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

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£666.00

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Erectile Dysfunction

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