Erectile Dysfunction Questionnaire

Body Measurements
What is your height? (cm)*
What is your weight? (kg)*
Each week how often do you train hard enough to raise a good sweat and for at least 40 minutes at a time. This is important as high Body Mass Index (BMI) in athletes reflects bone and muscle, rather than fat.*
- Virtually never / never
- Most or all weeks
- Some weeks
- What? Exercise? Are you mad?
In regards to exercise, do you rate yourself as:*
- Driven/ fanatical
- Enjoying regular exercise
- Dislike exercise
- "Relaxed"
Please enter the results of a blood pressure measurement from within the last six weeks (e.g. 120/80)*

Your Contact Information
Name*
Email*
Date of Birth*

DD
MM
YYYY
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Legal/ Consent

While we respect your informed decisions regarding your health care and will not communicate with any third party about you, if is important to remind patients that doctors should communicate to give you the best in health care.
Would you prefer us to inform your GP about this treatment?*
- Yes
- No
Please give your doctors name and postal details.*
I have read and agree to the terms and conditions, I am over 18 and that any treatment prescribed for me by askthedoctoruk clinic is for my personal use only.*
- Tick box to confirm
Terms and conditions
Further information:
http://www.nhs.uk/conditions/erectile-dysfunction/Pages/Introduction.aspx
Key information

How will my privacy be protected?
Your privacy is very important to us at askthedoctoruk clinic.

We protect your privacy by:  
- not emailing or texting you with medical information you do not request 
- not sharing your information without your consent - see our privacy guide 
- sending medicines out in a plain envelope

Your Specific Health Problem