Get Started with our Confidential Questionnaire

Your Town/Country:

Did your erectile dysfunction come on suddenly or over a longer period of time:

Have you ever been assessed for your erections by your GP or a specialist:

If Yes then by who:

If Other please state who:

Are you currently taking any of these medications for your erections?:

If you do not respond to these drugs, did they have an affect when you previously took them:

When you take the above medication what strength erection do you get:

Have you ever had any other treatment for your erectile dysfunction:

If Yes please list:

Have you been diagnosed with prostate cancer or an enlarged prostrate:

Have you been treated for prostate cancer or an enlarged prostrate in the last 18 months:

Unfortunately this renders you unsuitable for this treatment

What was your latest PSA:

Have you had a Prostate blood test:

If Yes what was the last result:

Have you ever suffered from any penile deformity - such as Peyronie's disease:

Are you taking any other prescription-only medicines, over-the-counter medicines, alternative medicines or recreational drugs:

If Yes please list:

In the last two months have you taken any medicine, including both prescription and non-prescription medicines, other than any medicine you have mentioned above:

If Yes please list:

Do you have any known allergies:

If Yes please list:

Do you have a condition where sexual activity is not advised:

Unfortunately this renders you unsuitable for this treatment

Do you suffer from angina or severe heart disease:

In the last six months have you had a heart operation, stroke or heart attack:

Unfortunately this renders you unsuitable for this treatment

Do you have a history of low blood pressure, fainting or, after lying down, do you get dizzy when you stand up:

Have you ever been diagnosed with diabetes or abnormal blood sugar levels:

Do you suffer from any other illnesses or conditions:

If Yes please list:

Have you ever had any operations:

If Yes please list with approximate dates:

Do you have or have you had high cholestorol:

Do you smoke:

Do you ever drink alcohol:

If yes how many units a week:

Height (ft):

Weight (stones):

Waist (round bellybutton in inches):

I confirm that I have not completed this questionnaire on behalf of another person.

I confirm that I am happy for the Team to contact me arrange a telephone appointment with the specialist.

I confirm that I am happy to pay the initial fee of £40 for this telephone consultation which I am aware is non-refundable (this will be taken at the time of booking).

I confirm that I am happy for Curing ED & The Consultant Urologist to keep my records if I proceed to treatment and to follow my treatment up with a further questionnaire by email.

I understand that the advice given is based on the answers I give.

Confirm

Confidential Medical Questionnaire

Contact Details

About Your ED

Current and recent use of medicines

Your Medical History

Heart, Health & Blood Pressure

Diabetes and blood sugar levels

General Medical History

Lifestyle Factors

Please enter your height, weight & waist (Imperial Units)

Informed Consent