Are you usually able to get an erection when you need to?

Are you usually able to keep an erection for as long as you need?

Are your erections usually firm enough for penetration?

Please tell us the main reason you are seeking ED treatment.

Have you used any ED treatments before?

Did you experience any side effects from the previous treatment?

Which side effects did you experience?

Please tell us about any other side effects you experienced.

Have you ever had a painful erection?

Unable to retract the foreskin (phimosis)

Foreskin stuck behind the head (paraphimosis)

Noticeable bend or deformity of the penis

What was this caused by?

Have you spoken to your doctor or a urologist about this condition?

Can you provide more details about what treatment(s) you have been advised to take for this condition?

This may have been diagnosed by a healthcare professional or measured at home.

Have you ever been told that you have high or low blood pressure?

High blood pressure and I take medication for this

High blood pressure but I am not on treatment

Low blood pressure (less than 90/50 mmHg)

Please can you tell us which applies to you?

Has your blood pressure been raised above 170/100 mmHg?

Please can you tell us when you last took your blood pressure and what the reading was?

<ul><li>What was your last blood pressure reading?</li><li>What medications do you take to treat your low blood pressure?</li><li>When were you first diagnosed with this condition?</li></ul>

It is not so common to have low blood pressure - please can you tell us

Do you often become breathless or experience chest pain during light exercise, such as walking up the stairs?

I have not spoken to my doctor about this

Have you been told by a doctor to avoid physical or sexual activity?

<ul><li>How long does it take for you to catch your breath?</li><li>Are you housebound given how severe this condition is?</li><li>What medications are you taking to support your lungs and heart?</li></ul>

Please tell us more about your symptoms and what happens when you experience them.

Do you have any medical conditions that affect your eyes?

NAION (Non-arteritic anterior ischemic optic neuropathy)

Do you have any of the following conditions?

Do you still have an ulcer?

<ul><li>What treatment have you had?</li><li>Are you still using the treatment?</li><li>Have you used ED treatment since having this diagnosis?</li><li>Are you waiting for any investigations, treatments or procedures for your condition?</li></ul>

Please tell us more about your condition so we can advise further.

Please tell us more about your condition so we can provide further advice.

Have you had a heart attack or stroke in the last 6 months?

<ul><li>When did this occur?</li><li>What treatment or procedures did you have (if any)?</li><li>What medications are you currently taking for this condition?</li><li>Have you used any ED treatments since this event?</li></ul>

Can you provide more details about your health so that we can advise further?

Nitrates (such as isosorbide mononitrate or dinitrate to treat angina)

Riociguat (to treat pulmonary arterial hypertension)

Protease inhibitors (including ritonavir, indinavir, nelfinavir and saquinavir - to treat HIV)

Alpha blockers (including alfuzosin, indoramin, terazosin, prazosin, doxazosin and tamsulosin)

Do you take any of the following medications?

Are you taking this medication long-term or to treat a current infection for 7-14 days?

<ul><li>When did you first start using this medication?</li><li>When was the last time you used this treatment?</li><li>How often do you use this medication?</li></ul>

Please can you tell us about your usage of this medication so we can understand your situation better

Please can you tell us the name of the medication that you are prescribed (either brand or generic name). Please also tell us if you take this as a daily medication or as PrEP.

<p>If you need help or support with your treatment our helpful medical team can communicate with you via telephone or email. Please reach out to us.</p>

Are you aware that this medication can interact with erectile dysfunction treatments and you should ensure that you space these treatments at least 6 hours apart.

<ul><li>An erection that lasts longer than 4 hours</li><li>Blurred vision</li><li>Sudden decrease or loss of vision in one or both eyes</li><li>Chest pain</li></ul>

Do you agree to seek urgent medical attention if you experience any of the following symptoms:

What is your biological sex?

Are you currently, or are you planning to become, pregnant or breastfeeding?

Confirm which applies to you

When is your due date?

How old is your baby (in months)?

Is your baby exclusively breastfed?

When was your last period?

Please provide details of any medication you are currently taking

Are you currently taking any medication?

<ul><li>You have any medical conditions that you have not already mentioned</li><li>You have, or previously had, any mental health problems that required specialist mental health support or hospitalisation</li><li>You have had major surgery</li><li>You have heart problems or have had a stroke</li><li>You have decreased kidney or liver function</li></ul>

Do any of the following apply:

Do you have any allergies or sensitivities?

Select the allergies or sensitivities you have:

Has your allergy caused an anaphylactic reaction or for you to be hospitalised before?

Please tell us which medicines or ingredients you are allergic to:

Have you used this medication in the past?

We will do our best to accommodate requests for specific brands, where possible, for generic treatments. This is not applicable for branded treatments.

Are there specific brands that you would prefer us to provide, if possible?

Do you consent to us accessing your NHS Summary Care Record (the medical details held by your GP) or requesting further information on your medical history from your GP?

Do you consent to us sharing consultation information with your GP?

<p>Do you consent to us requesting further information on your medical history from your GP? This is to ensure that any treatment we recommend for you is appropriate and safe. Any references to "we" or "us" refers to ABSM Healthcare Limited.</p>

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