Questions Related to Impotence

In order to prescribe treatments for Impotence our doctor needs some information regarding this specific condition. Please complete the following as accurately as possible.

Do you suffer from erectile dysfunction (E.D.) otherwise known as impotence? This means you may have difficulty achieving an erection sufficient for penetration or maintaining an erection following penetration.

Yes Sometimes No

How long have you been suffering with the problem? Please provide an estimated time in years/months.

Do you have a condition where sexual activity is inadvisable (eg severe cardiovascular disorders such as unstable angina or severe cardiac failure)?

Yes No

Do you have a hereditary degenerative retinal disorder such as retinitis pigmentosa?

Yes No

Are you taking the HIV protease inhibitor Ritonavir?

Yes No

Are you taking saquinavir, erythromycin, ketoconazole or itraconazole (please double check any medication bottles/packs that you may have)?

Yes No

Are you taking nitric oxide donors (such as amyl nitrate) or nitrates in any form such as poppers?

Yes No

Do you suffer from Peyronie's disease?

Yes No

Are there any other health/medical details you feel we should know? Please do not use abbreviations!

Yes No

Are you taking: alpha-blockers (Sometimes used to treat high blood pressure or prostate enlargement) including alfuzosin, doxazosin, indoramin, prazosin, tamsulosin, terazosin ?

Yes No

Which methods, if any, have you already used to try to remedy your condition? Please list any prescription treatments such as Viagra, Cialis or Levitra including dose and frequency.

Erectile dysfunction (ED) can be an indicator for diabetes, raised cholesterol and heart disease. For this reason, we advise you to go and see your regular doctor for a general health check in the near future. This is particularly important if ED is occurring frequently.
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