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How long have you been experiencing erectile dysfunction?

How often do you experience difficulty achieving or maintaining an erection?

Do you wake up with morning erections?

Are you currently sexually active or planning to be in the near future?

Is there anything else you'd like to share about your symptoms?

Have you recently experienced chest pain, breathlessness, or fainting during sexual activity?

Have you had recent unexplained weight loss or night sweats?

Do you have pain, deformity, or curvature in your penis (e.g. Peyronie’s disease)?

Have you ever had a prolonged or painful erection (priapism)?

Do you take nitrate medications (e.g. GTN spray, isosorbide) for chest pain?

Have you had recent eye problems (e.g. sudden vision loss or NAION)?

Do you have any allergies to ED medications (e.g. sildenafil, tadalafil)?

Please list any medications you are currently taking

Have you used ED medication before?

Do you have a treatment preference?

How often do you expect to need medication?

💡 Note: Sildenafil typically lasts 4–6 hours; tadalafil may last up to 36 hours.

Erectile Dysfunction Consultation Form