Erectile Dysfunction Questionnaire

Prosper Healthcare supporting you on your journey

We are going to ask some questions so we can assess whether we can help you.

This questionnaire is like a consultation. After completing the questionnaire, we will arrange a meeting with our practitioner to issue the appropriate treatment.

On average this questionnaire takes 7 minutes to complete.

If you prefer to book an appointment without filling the questionnaire, then no problem! Use our appointment booking service to speak to one of our clinicians.

Section 1 - Declaration

By proceeding and submitting the questionnaire, you confirm that you:

GDPR Agreement *

I consent to having this website store my submitted information so they can respond to my inquiry.

Check all five boxes to Proceed *

Are completing this questionnaire for yourself and to the best of your knowledge
Will disclose any medical conditions, serious illnesses or operations you have had
Will disclose any prescription medication you currently take -
Are registered with a GP practice in the UK.
Accept our Terms and Conditions

Section 2 - Information About You

Getting to know you better so we can provide a bespoke service

What is your gender identity? *

Woman
Man
Binary
Prefer not to say

Name *

First

Middle

Last

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

When is your date of birth *

This service is only available if you are over 18

Email *

Phone

Purpose of your contact number is to call you about this questionnaire only. It is not mandatory for you to enter.

Using the explanation of erection hardness score, please select one of the following? *

Grade 1 – penis is larger but not hard
Grade 2 – penis is hard but not hard enough for penetration
Grade 3 – penis is hard enough for penetration, but not completely hard
Grade 4 – penis is completely hard and fully rigid
Prefer not to say

The erection hardness score (EHS) can also be helpful in discussing erections and allows health professionals and patients to have a visual, easy and brief method of understanding of what is meant by the quality of the erection.

Are you currently being treated for erectile dysfunction? *

How long have you had the symptoms of erectile dysfunction? *

Less than one month
Less than six months
Less than twelve month
More than twelve month

Have you tried medication but was ineffective on 8 or more occasions? *

Yes
No
Not sure

Which of the following do you think are contributory factors? *

Sexual experience
Relationship problems
Religious or cultural beliefs
Unclear sexual or gender preference
None of the above
Other

Details of other

Do you think you can improve on any of the following lifestyle measures? *

Smoker
Drink Alcohol
Illicit Drugs
Overweight
Poor Diet
Anxiety
Depression
None of the above

Are you a smoker?

Never smoked
Ex-smoker
1-10 cigarettes
11-20 cigarettes
20+ cigarettes
Vape
Other

If you smoke cigars or pipe choose other

Do you drink alcohol

I do not drink alcohol
I drink less than 14 units a week
I drink more than 14 units a week
I drink but unsure how much units I drink per week

How much do you exercise per week?

More than 120 minutes
90-120 minutes
Less than 90 minutes
None

How would you describe your diet?

Healthy
Balanced
Unhealthy
Snacker

Do you taken any illicit drugs? *

None
Cocaine
Cannabis
Heroin
Other

Details of other

Do you have any stressors? *

Financial
Relationships
Employment
Housing
Other
None of the above

Details of other

Section 3 - Suitability of Treatment

Lets see if medication is suitable for you and get you the right treatment plan

Do you have any allergies or sensitivities? *

Please state your allergies or sensitivities

Have you had any previous treatments for erectile dysfunction? *

Please state reason for stopping (failed, side-effects, resolved, etc)

Include what has and not helped including drug and non-drug therapies

Are you aware of any liver or kidney problems? *

Yes, I have liver problems
Yes, I have kidney problems
I am unsure
None

Are you taking any of the following medications? *

Anticholinergics (solifenacin, tolterodine)
Beta-blockers - lol (bioprolol or propranolol)
Clonidine
Digoxin
Diuretics (furosemide)
Gemfibrozil
GTN spray (angina)
Lithium
MAOIx (moclobemide)
Methydopa
Nitrates (angina)
Oestrogen/progestogens
Steroids
Verapamil
Other
Finasteride or dutasteride
None of the above

Drugs can affect sexual performance. Are you on any of the following:

Other

Do you have any other medical conditions? *

includes herbal remedies, over-the-counter medication, recreational drugs

Which medical conditions do you have?

Section 4 - Examinations and Blood Tests

Physical examinations § All patients should have a focused physical examination. § Examination of the external genitalia and digital rectal examination may be indicated. § Blood pressure, heart rate, waist circumference and weight should be measured. Laboratory testing The choice of investigations depends on the individual circumstances of the patient. § The following tests are recommended for all patients: § serum lipids, § fasting plasma glucose, and § HbA1C § Serum prostate specific antigen and testosterone levels may also be indicated. Why is this important? Men with erectile dysfunction are at significantly increased risk of heart attack, stroke and coronary heart disease. So, you should have these tests done to evaluate your risk.

Are you aware if you have had the following blood tests? *

Diabetes (HbA1c)
Lipid or Cholesterol profile
Testosterone
PSA (can be an indicator for prostate cancer)
Prolactin
Thyroid function

If you have not had the following blood tests, we would recommend the above to be tested

Do you have any of the following? Or, do you think any could have affected your performance? *

Anxiety or depression
Cancer
Current relationship
Diabetes
Family / social pressures
Genital or urinary condition
Heart related condition
Negative sexual experience
Hyperthyroidism
Hypogonadism
Lack of desire
Lack of orgasm
Pain
Religious / Cultural

Signature *