Help us prepare for your appointment by completing this form in advance.
This form includes the IIEF-5 (a short, validated questionnaire that measures ED severity) plus a few safety questions.
We know this isn't the most comfortable topic to discuss, but the form makes it easier - you answer privately, at your own pace, and your doctor arrives fully informed. Takes about 4 minutes.
IIEF-5 scoring: 5-7 severe ED, 8-11 moderate, 12-16 mild-moderate, 17-21 mild, 22-25 no ED
Morning erections suggest adequate blood flow - their presence points to psychological rather than physical causes
Depression can contribute to ED
Heavy pornography use can contribute to ED in some men - this is confidential
ED is often the first sign of cardiovascular disease - these questions help assess your overall vascular health
RED FLAG - requires urgent cardiac assessment
ABSOLUTE CONTRAINDICATION - PDE5 inhibitors (Viagra, Cialis) CANNOT be used with nitrates - potentially fatal drop in blood pressure
Also a nitrate - same contraindication with PDE5 inhibitors
Anything you would like your doctor to know before your appointment.
Your information is sent securely to your doctor at LoveMyLife. We will not share your details with third parties. By submitting this form, you consent to LoveMyLife contacting you regarding your appointment.