Question 1 of 19
Are you able to get an erection for sexual activity?
Question 2 of 19
Is it difficult to maintain your erection during sexual activity?
Question 3 of 19
Do you often have an erection when you wake up in the morning?
Question 4 of 19
Do you currently smoke, or have been a regular smoker in the past 5 years?
Question 5 of 19
Do you drink more than 2 alcoholic beverages a day on average?
Question 6 of 19
Do you have any difficulties with urination such as reduced flow, pain on passing urine, blood in your urine?
Question 7 of 19
Do you experience low blood pressure, dizziness, faints or collapses?
Question 8 of 19
Have you had any of the following conditions:
Question 9 of 19
Do you have any of the following: Peyronie’s disease, previous injuries to the penis, inability to retract foreskin (if not circumcised)?
Question 10 of 19
Have you ever had a condition affecting your spine, pelvis or genital area (such as spinal injury, incontinence, abscess)?
Question 11 of 19
Have you ever been advised by a doctor to not have sex or do vigorous exercise?
Question 12 of 19
Do you have any conditions affecting your kidneys, urinary system, digestive system or liver?
Question 13 of 19
Do you have either of these eye conditions: non-arteritic ischaemic optic neuropathy (NAION) or a retinal problem such as retinitis pigmentosa?
Question 14 of 19
Do you experience depression, low moods, anxiety or any other psychological or mental health conditions?
Question 15 of 19
Do you have any other health conditions?
Question 16 of 19
Are you currently taking any medications?
Question 17 of 19
Do you have any allergies?
Question 18 of 19
Is there any further information you would like to provide?
Question 19 of 19
Would you like to have a video or telephone consultation?