Consultation - Chemist 69

Erectile Dysfunction

Erectile dysfunction (ED) is the inability to achieve or maintain an erection sufficient for sexual intercourse. Erectile dysfunction is a common condition. It occurs more frequently with age, affecting up to 50% of men aged between 40-70, and up to 70% of men over the age of 70. Causes include psychological factors, chronic diseases, and medications. Treatment includes lifestyle changes, oral medications, and therapy for underlying conditions. These treatments have been found to be effective in up to 80% of men, and are considered safe and cost-effective.

Please fill out the form below so that our clinicians can determine if the treatment will be suitable for you to take.

1 About Your Health

Your health and safety are our top priorities. Please provide accurate and complete information during your consultation so we can recommend the most appropriate treatment for you.

Question 1:What is your date of birth?

Question 2:What is your gender?

Female

Male

Question 3:Do you have any known allergies?

Question 4:Do you have any chronic conditions? (e.g., diabetes, hypertension, asthma, etc.)

If yes, please detail them here, otherwise please type N/A

Question 5:Are you currently taking any medications?

If yes, please detail them here, otherwise please type N/A

Question 6:Have you had any surgeries in the past year?

If yes, please detail them here, otherwise please type N/A

Question 7:Do you smoke?

Question 8:Do you consume alcohol?

If yes, how much a day/weekly?

Question 9:What is your typical diet like? (e.g., balanced, high-fat, spicy foods)

Question 10:How often do you exercise? (e.g., daily, weekly, rarely, never)

2 About Your Condition

Please provide accurate and honest details during your consultation. This helps us offer the safest and most effective treatment for you.

Question 1:How long have you been experiencing symptoms of erectile dysfunction?

Please provide more detail here

Question 2:Have you been diagnosed with erectile dysfunction by a healthcare professional?

Question 3:Have you had any tests to confirm the diagnosis? (e.g., blood tests, ultrasound, psychological evaluation)

Question 4:How often do you experience difficulty achieving or maintaining an erection? (e.g., occasionally, frequently, always)

Occasionally

Frequently

Always

Question 5:Are there specific situations or factors that worsen your symptoms? (e.g., stress, fatigue, certain medications)

Question 6:Have you experienced any other symptoms alongside erectile dysfunction? (e.g., low libido, anxiety, depression)

Question 7:Have you been prescribed medication for erectile dysfunction before?

Question 8:Are you currently taking any medication for erectile dysfunction?

Question 9:Have you experienced any side effects from your current or past erectile dysfunction medications?

Question 10:Have you tried any non-medication treatments for erectile dysfunction? (e.g., lifestyle changes, therapy, vacuum devices)

Question 11:Have you used over-the-counter treatments for erectile dysfunction?

3 The Agreement and Consent

Please read the Agreement and Consent statements carefully during your consultation. They contain important information to help you stay informed and safe throughout your treatment.

Question 1:Understanding of Risks

Yes

Question 2:Medical Guidance

Yes

Question 3:Consent to Share Information

Yes

Question 4:Confirmation

Yes

1 About Your Health
2 About Your Condition
3 The Agreement and Consent

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Acid Reflux

Acne

Anxiety

Asthma

Contraception

Eczema

Erectile Dysfunction

Hair Loss

HRT

Malaria Prevention

Period Delay

Premature Ejaculation

TEST CONDITION

Weight Loss

Travel Clinic

Assessment for Erectile Dysfunction

Erectile Dysfunction

1 About Your Health

Question 1:What is your date of birth?

Question 2:What is your gender?

Question 3:Do you have any known allergies?

Yes

Question 4:Do you have any chronic conditions? (e.g., diabetes, hypertension, asthma, etc.)

Yes

Question 5:Are you currently taking any medications?

Yes

Question 6:Have you had any surgeries in the past year?

Yes

Question 7:Do you smoke?

Yes

Question 8:Do you consume alcohol?

Yes

Question 9:What is your typical diet like? (e.g., balanced, high-fat, spicy foods)

Yes

Question 10:How often do you exercise? (e.g., daily, weekly, rarely, never)

Yes

2 About Your Condition

Question 1:How long have you been experiencing symptoms of erectile dysfunction?

Question 2:Have you been diagnosed with erectile dysfunction by a healthcare professional?

Yes

Question 3:Have you had any tests to confirm the diagnosis? (e.g., blood tests, ultrasound, psychological evaluation)

Yes

Question 4:How often do you experience difficulty achieving or maintaining an erection? (e.g., occasionally, frequently, always)

Question 5:Are there specific situations or factors that worsen your symptoms? (e.g., stress, fatigue, certain medications)

Yes

Question 6:Have you experienced any other symptoms alongside erectile dysfunction? (e.g., low libido, anxiety, depression)

Yes

Question 7:Have you been prescribed medication for erectile dysfunction before?

Yes

Question 8:Are you currently taking any medication for erectile dysfunction?

Yes

Question 9:Have you experienced any side effects from your current or past erectile dysfunction medications?

Yes

Question 10:Have you tried any non-medication treatments for erectile dysfunction? (e.g., lifestyle changes, therapy, vacuum devices)

Yes

Question 11:Have you used over-the-counter treatments for erectile dysfunction?

Yes

3 The Agreement and Consent

Question 1:Understanding of Risks

Question 2:Medical Guidance

Question 3:Consent to Share Information

Question 4:Confirmation

Assessment Progress

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