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Male Patients - Application for Erectile Dysfunction Treatment (backup copy)

Erectile Dysfunction

What is the Erectile Dysfunction?

Erectile dysfunction (also known as ED) is defined as the inability to gain and maintain an erection hard enough for sex. It is a common condition and most men experience symptoms of ED at some point in their lives. If you experience difficulties with your erections more than once in every five attempts, you may be suffering from erectile dysfunction.

Although men of all ages can experience these symptoms, your risk of ED increases with age. This condition is believed to affect 30% – 50% of men between 40 and 70 and almost 70% of all men over the age of 70.

Complete a short questionnaire and choose your treatment, then our doctors will review your order and prescribe your chosen medicine.
Male Patients
Note: We can only ever prescribe for this treatment for patients that are at least 18 years of age.

HOW IT WORKS


Dr. Jody is online now


  • Dr. Jody Shanahan-Prendergast
  • M.D., MRCGP, FRACGP

Irish Medical Council Register Number: 425861

STEP 1 OF 4

What medicine would you like a prescription for? *

What is your age? *

Select from the dosages below, if unsure, select 'Don't Know' *

Has a doctor prescribed ED medication for you in the past? *

Are you currently using the treatment you have requested? *

By whom was this last prescribed for you? *

When did you last have your blood pressure taken? *

If known please use the input below to enter your blood pressure (eg: 120/80 mmHg)

Were you ever treated in hospital for any previous Accidents, Operations, Investigations or Illnesses? *

Do you have any sensitivity to medicines or any allergies (e.g. Hay Fever, Animal Dander, Nuts etc)? *

STEP 2 OF 4

When did you notice this problem first? *

Is the problem is getting worse or staying at the same level of difficulty? *

Did this problem occur gradually or all of a sudden? *

When was the last time you had sexual intercourse? *

Please describe what happened in terms of the quality of the erection. Was it fully stiff or was it soft? *

Was the erection sufficient for you to manage penetration? *

Was the erection sufficient for you to manage to climax? *

When having intercourse, has the erection ever gone soft to stop you being able to penetrate? *

How often do you have morning erections? *

During masturbation, does ejaculation occur? *

During masturbation would the erection be hard or not? *

STEP 3 OF 4

Have you ever been treated for any psychological problems such as anxiety or reactive depression? *

Have you ever been treated for any psychological problems (such as anxiety, panic attacks or reactive depression), or for psychiatric problems (such as, mania, bipolar disorder or schizophrenia)? *

Are you in a relationship at this time? *

Does this condition affect your relationship?

Do you smoke? *

Do you take alcohol (1 unit = 125ml wine, ½ pint beer, bar measure of spirits)? *

Are you currently taking any prescribed medications? *

Are you currently taking any non-prescribed medications? *

Are you currently taking any recreational drugs? *

Do you take any regular exercise? *

STEP 4 OF 4

What is your birth sex? *

Please use the input if known your height (enter as centimeters)

Please enter your weight if known (enter as kg)

I confirm that I have read and understood this and my answers are fully correct and true. *