Full Name*

Date of Birth*

Contact (phone/email)*

Please tick to confirm:
I confirm I am male, aged 18 or over, and I am completing this questionnaire for myself.I understand that the ED medication I request will be for my sole use.I consent to Batley Pharmacy forwarding relevant details of this consultation to my GP if required.I understand that if my responses indicate a contra-indication or red-flag condition, I may be referred to my GP or a specialist.

How long have you experienced difficulty achieving or maintaining an erection sufficient for sexual activity?
Less than 3 months3–6 monthsMore than 6 monthsOccasional only

Q1. How do you rate your confidence that you could get and keep an erection?
Very low (1)Low (2)Moderate (3)High (4)Very high (5)

Q2. When you had erections with sexual stimulation, how often were your erections hard enough for penetration (entering your partner)?
No sexual activity (0)Almost never or never (1)A few times (much less than half the time) (2)Sometimes (about half the time) (3)Most times (much more than half the time) (4)Almost always or always (5)

Q3. During sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner?
Did not attempt intercourse (0)Almost never or never (1)A few times (much less than half the time) (2)Sometimes (about half the time) (3)Most times (much more than half the time) (4)Almost always or always (5)

Q4. During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?
Did not attempt intercourse (0)Extremely difficult (1)Very difficult (2)Difficult (3)Slightly difficult (4)Not difficult (5)

Q5. When you attempted sexual intercourse, how often was it satisfactory for you?

Did not attempt intercourse (0)Almost never or never (1)A few times (much less than half the time) (2)Sometimes (about half the time) (3)Most times (much more than half the time) (4)Almost always or always (5)

For clinician use – ED severity (based on SHIM total):
1–7: Severe ED8–11: Moderate ED12–16: Mild to Moderate ED17–21: Mild ED22–25: No or minimal ED

Have you ever used any treatment for erectile dysfunction?
YesNo

Heart attack, stroke or mini-stroke (TIA) in the last 6 months
YesNo

Currently advised to avoid sexual activity or strenuous exercise
YesNo

Currently advised to avoid sexual activity or strenuous exercise
YesNo

Chest pain or breathlessness on light or moderate physical activity
YesNo

Uncontrolled high blood pressure or low blood pressure
YesNo

Heart problems (e.g., angina, arrhythmia, heart failure, valvular disease)
YesNo

Peripheral vascular disease or circulation/arterial disease
YesNo

Diabetes mellitus
YesNo

Kidney or liver disease (or impaired kidney/liver function)
YesNo

Bleeding disorders (e.g., haemophilia) or stomach/peptic ulcers
YesNo

Blood disorders (e.g., sickle cell disease, multiple myeloma, leukaemia)
YesNo

Deformity of penis (e.g., Peyronie’s), painful erection (priapism)
YesNo

Severe visual loss due to circulation or inherited eye disease
YesNo

Any other significant illness not listed above
YesNo

If yes to any of the above, please provide details (including dates if known):

Are you currently taking nitrates or any other nitric oxide donor?
YesNo

If yes, please list:

Are you taking alpha-blockers (e.g., tamsulosin, doxazosin), or any other medications for prostate, blood pressure, heart disease, or urinary symptoms?
YesNo

If yes, please specify:

Are you taking any other prescription medications, over-the-counter medicines, herbal remedies or recreational drugs?
YesNo

If yes, please list:

Do you smoke?
YesNo

If yes, how many per day?

Do you drink alcohol?
YesNo

If yes, roughly how many units per week?

Do you have any allergies, including drug allergies?
YesNo

If yes, please specify:

Are there any other health issues, symptoms or concerns not covered above?

YesNo

If yes, please provide details:

I confirm that I have answered the questions fully and honestly. I understand that if I have indicated any red-flag condition or contra-indication, I may not be eligible for ED medication through this service and may be referred to my GP.