📞 (+44) 07770 474443 . ✉ enquiries@mmsclinic.co.uk

Part of MMS Clinic Group – Doctor‑Led Online & In‑Clinic Services

Part of MMS Clinic Group – Doctor‑Led Online & In‑Clinic Services

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Doctor-Led Erectile Dysfunction Patient Questionnaire

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)
Common Questions

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