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Erectile Dysfunction Consultation
In the last 6 months, have you had a heart attack or a stroke?
(Required)
Yes
No
Do you feel very breathless or get chest pain with light to moderate exercise such as walking fast for 20 minutes or climbing 2 flights of stairs?
(Required)
Yes
No
Are you taking any of these medicines or drugs?
(Required)
Nitrate medicines for chest pain
Any recreational drugs such as poppers
Any other regular medication
No medication
Do you have any of the following health conditions?
(Required)
Liver or kidney disease
Blood diseases: leukaemia, sickle cell anaemia, multiple myeloma
Bleeding issues: haemophilia or stomach ulcers
A heart problem, uncontrolled high blood pressure, low blood pressure, unstable angina or heart failure
No Health Conditions
Unsure
Do you have Peyronie’s disease or any other deformation of the penis?
(Required)
Yes
No
Have you ever had loss of vision because of damage to the optic nerve (known as NAION) or have an inherited eye disease (e.g. retinitis pigmentosa)?
(Required)
Yes
No
Do you have any allergies or intolerances (e.g. lactose intolerance)?
(Required)
Yes
No
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