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Doctor-Led Erectile Dysfunction Patient Questionnaire

Confidential • Non-judgemental • Evidence based

This questionnaire helps our clinicians assess whether treatment for hair loss may be appropriate and safe for you.
Submitting this form does not guarantee treatment

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Step 1 of 12



Section 1 - Your details

1. Are you requesting treatment for yourself (not for someone else)? *
2. What is your gender? *

(We may still advise you to contact your GP where needed.)

Section 2 - Your main concern and ED severity

6. Which best describes the problem? *
7. How long has this been happening? *
8. Did it start: *
9. In the last 6 months, how often have you had difficulty getting/keeping an erection during sexual activity? *

10. Over the past 6 months (IIEF-5):

11. Do you get erections during masturbation? *
12. Do you wake with morning/night erections? *
13. Any pain with erections or sex? *

Section 3 - Red flags requiring urgent care

14. Have you had any of the following recently? (tick any)

If ticked any of the above, please seek immediate medical advice—your own GP/111/999/A&E as appropriate.

Section 4 - Cardiovascular fitness and sexual safety

15. Have you been told by a clinician to avoid sexual activity or strenuous exercise? *
16. Can you climb 2 flights of stairs or walk briskly for 5 minutes without chest pain, severe breathlessness, or dizziness? *
17. Do you have diagnosed heart disease? (tick any)
18. Have you had a heart attack or stroke in the last 6 months? *
19. Blood pressure:

Do you know your most recent BP reading?

Have you been told you have uncontrolled high BP or very low BP? *

Section 5 - Medical history relevant to ED causes and prescribing safety

21. Have you been diagnosed with any of the following? (tick all that apply)

Metabolic / vascular Hormonal Neurological Urological / Pelvic Kidney / Liver / Blood Eye Mental health
22. Do you have symptoms that could suggest low testosterone? (tick any)

Section 6 - Medication safety

23. Are you taking any medicines or substances (prescription, OTC, supplements, recreational)? *
24. Do you take nitrates for chest pain (GTN spray/tablets/patches), isosorbide mononitrate/dinitrate, or nicorandil, or use amyl nitrate/poppers? *
25. Do you take riociguat (for pulmonary hypertension)? *
26. Do you take alpha-blockers (for prostate symptoms or BP) such as tamsulosin, alfuzosin, doxazosin, terazosin? *
27. Do you take any of the following that can interact (CYP3A4 etc.)? (tick any)
28. Do you take medicines that can contribute to ED? (tick any)

Section 7 - Lifestyle and risk factors

30. Smoking: *
31. Alcohol: *
32. Recreational drugs (including cocaine, cannabis, poppers): *
33. Activity level:
34. Sleep:

Section 8 - Relationship and psychological context

34. Are you in a relationship currently? *
35. Any recent stressors (work, finances, relationship, bereavement)? *
36. Performance anxiety a factor? *
37. Do you feel safe at home and in relationships? *

Section 9 - Treatment preferences

39. Have you used ED treatment before? *

40. If used before:

41. What matters most to you?
42. Preferred dosing style:
43. How often do you expect to engage in sexual activity that involves using these medications? *

Section 10 - Investigations and monitoring

43. In the last 12 months, have you had any of these checked?

Blood pressure
Blood glucose / HbA1c
Lipids (cholesterol)
Testosterone (morning)
44. Would you be willing to arrange a blood test if clinically recommended? *

Section 11 - Safety warnings patient must acknowledge

45. Please tick to confirm:

Section 12 - Consent for remote assessment

45. I consent to assessment and prescribing via an online/remote consultation pathway, and I understand additional questions or a live consultation may be required for safety. *
46. Preferred outcome:
47. I wish to request: (request may be changed for safety)

More Services

The sections below provide further details on available services and associated fees. All treatments are subject to clinical assessment and suitability.

Home Visit
Within 20 miles of Coventry (09:00–22:00): £279

Patients requesting a home visit are required to book an initial telephone consultation (£45). If the home visit proceeds following this assessment, the £45 fee will be deducted from the home visit cost.

  • Injection volume under 2 ml: £250

  • Injection volume over 5 ml: £300

Simple Skin Lesions
Skin tags, seborrhoeic warts, simple moles, lipomas under 1 cm:
£250 per lesion

Large or Cystic Lesions
Epidermoid, pilar, sebaceous, or ganglion cysts, large lipomas:
£350 per lesion

Additional Lesions

  • Additional skin lesion: £50

  • Additional cystic lesion: £100

Ingrown Toenail Surgery
£379 per toe

Histology
All pigmented lesions must be sent for histology or at clinical discretion or patient preference:
£100 per sample

Blood tests, allergy testing, STI screening, cultures, swabs, and imaging referrals are available where clinically appropriate.

Prices depend on the tests required and will be discussed following telephone, video, or face-to-face assessment.

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Common Questions

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