Erectile Dysfunction Form

Complete Your Appointment in 5 Simple Steps: Choose your type, fill in details, and confirm!

Patient Information

Full Name

HSN Number

DOB

Contact Number

Allergies

No previous diagnosis of erectile dysfunction (ED) by a primary care provider

Trauma to genital area, pelvis or spine since ED diagnosis

Symptomatic or severe hypotension (<90/50 mmHg) or conditions(s) that predispose to hypotension

Serious cardiovascular disease (including angina, recent myocardial infarction, stroke, heart failure, arrhythmias)

Poor control or recent emergence of symptoms of potentially contributing conditions (e.g. diabetes, hypertension)

Renal impairment (CrCl = ml/min)

Hepatic impairment

Medical History

Nitrates (all dosage forms including “Poppers”)

CYP3A4 inhibitor (Name of drug)

CYP3A4 inducer (Name of drug)

Alpha-blocker (both selective and non-selective)

Multiple antihypertensive medications

Medication(s) which could cause or contribute to ED (Name of drug)

Other relevant medication(s):

Drug History

Available: Mon - Fri: 10 AM - 6 PM, Saturday: 10 AM - 2 PM

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Appointment Time

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