HealthRX.com · Printable question sheet
Erectile dysfunction visit sheet for PDE inhibitor and testosterone questions
Fill this in by hand before a visit about erectile dysfunction with your prescriber or pharmacist. Use it to list medicines, heart history, lab results and each erection attempt so the visit covers the first-line and second-line options discussed in this article.
Medicines and heart history
Write what you know. Leave blank anything you are unsure about and ask at the visit.
Erection medicine tried so farName only, for example sildenafil, tadalafil, vardenafil or avanafil
Any nitrate or nitrite use, including poppersWrite yes or no and the name
Heart conditions, recent heart attack or strokeWrite the year and any treatment
Blood pressure medicines and diuretics
Antidepressants, beta-blockers or other daily medicines
Alcohol and smoking habitsWrite how much and how often
Bring and confirm before the visit
Bring copies or photos if originals are not available.
- Bring a full list of all medicines, supplements and over-the-counter products
- Bring recent results for morning testosterone, glucose, lipids, thyroid and prolactin
- Note the date your erection problems started and whether they are sudden or gradual
- Confirm whether you have any prior prostate surgery or pelvic treatment
- Check with your pharmacist which of your current medicines interact with nitrates
- Write down your questionnaire score if your clinic has used one before
Erection attempt record
Record each attempt for several weeks before the visit. Note the medicine name and what you ate or when you took it.
| Date | Medicine name | Timing or food notes | Result |
|---|---|---|---|
Questions to ask at the visit
- Which first-line medicine is most suitable for my heart and other conditions?
- Should my cardiovascular risk be checked before I start any erection medicine?
- How long should I try one medicine before we decide it is not working?
- Would a once-daily option or an as-needed option suit my schedule and cost?
- Could low testosterone or a thyroid problem be part of my symptoms?
- Would a vacuum device, injection or lifestyle change be reasonable for me?
- What symptoms would mean I need urgent care after taking any medicine?
This sheet records information for a conversation with your prescriber or pharmacist. It does not replace their instructions or the medication's prescribing information.