Quiz – ED

Men’s Health – Erectile Dysfunction
Pre-consultation Assessment

Please complete this short quiz to book in your initial consultation. It will only take 5 minutes and will help our doctors better understand your unique circumstances.

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Name
Current Address
You will receive a confirmation to this email address.
Date of Birth
What was your sex at birth?
Are you pregnant or breastfeeding?
Do you have a Medicare number or IHI?
Just to be cautious, do you suffer from any of the following?
Do you use any recreational drugs?
How often do you exercise?
Do you smoke or vape?
How many coffees or other caffeinated beverages do you drink per day?
How would you rate your average night's sleep?
How would you rate your mood recently?
A few questions about your specific condition – only a health practitioner will see this information.
Have you ever taken or used any medications or supplements for ED before?
When was your last blood pressure test?
If so, what was the blood pressure reading?
Have you ever suffered from any of the following medical conditions?
Do any of the following apply?
Do you experience any of the following symptoms when passing urine?
Are you looking for a specific medication?
Do you prefer to have planned or spontaneous sex?
What seems to be the problem?
Have you experienced issues with PE (premature ejaculation)?
Do you ever wake up with an erection?
When are you having trouble getting an erection?
Do you have issues getting and staying hard when masturbating?
Do you think there could be psychological causes for your ED (such as anxiety or depression)?
Do you confirm that the information you have given is true and accurate, and is solely for yourself and if prescribed a medication, you will review the information supplied regarding the medication and side effects?
Do you have a High Blood?