Consultation - Mentor Pharmacy

Do you currently have, or are you receiving treatment for, any medical conditions or surgeries?

Have you ever had any of the following?

Have you taken any of the following recreational drugs within 6 months; poppers, amyl, butyl nitrates, methamphetamine, meth, cocaine, MDMA or ecstasy?

Yes

No

Have you tried traditionally available medication for erectile dysfunction medications?

Yes

No

Which of the following treatments have you used in the past?

Was this effective for you?

Yes

No

no match

Acne

Asthma

Contraceptives

Eczema and Dermatitis

Erectile Dysfunction

Hay Fever

Menopause

Shingles

Urinary Tract Infection (UTI)

Ear Wax Removal

Private Blood Tests

Assessment for Erectile Dysfunction

1 Group 1

Enter your name

How old are you

How often do you have trouble getting an erection?

2 Group 2

Have you been told to refrain from strenuous physical activity?

Do you experience shortness of breath or chest pain during light activity, such as a 20 minute walk or climbing two flights of stairs?

Do you have any allergies or medication reactions? Include any allergies to food, lactose, dyes, prescription or over the counter medicines, such as antibiotics, allergy medications, herbs, vitamins, supplements or anything else

Free text

Are you taking any medication, including anything bought over the counter? Ensure you select yes if you take prescription medication for any chronic medical condition such as, diabetes, high cholesterol or high blood pressure

free text

Just to confirm, are you taking any of the following medication?c

3 Group 3

Do you currently have, or are you receiving treatment for, any medical conditions or surgeries?

free text

Have you ever had any of the following?

Have you taken any of the following recreational drugs within 6 months; poppers, amyl, butyl nitrates, methamphetamine, meth, cocaine, MDMA or ecstasy?

Have you tried traditionally available medication for erectile dysfunction medications?

Which of the following treatments have you used in the past?

Was this effective for you?

Assessment Progress

Quick Links

Acne

Asthma

Contraceptives

Eczema and Dermatitis

Erectile Dysfunction

Hay Fever

Menopause

Shingles

Urinary Tract Infection (UTI)

Ear Wax Removal

Private Blood Tests

Assessment for Erectile Dysfunction

1 Group 1

Enter your name

How old are you

How often do you have trouble getting an erection?

2 Group 2

Have you been told to refrain from strenuous physical activity?

Do you experience shortness of breath or chest pain during light activity, such as a 20 minute walk or climbing two flights of stairs?

Do you have any allergies or medication reactions? Include any allergies to food, lactose, dyes, prescription or over the counter medicines, such as antibiotics, allergy medications, herbs, vitamins, supplements or anything else

Free text

Are you taking any medication, including anything bought over the counter? Ensure you select yes if you take prescription medication for any chronic medical condition such as, diabetes, high cholesterol or high blood pressure

free text

Just to confirm, are you taking any of the following medication?c

3 Group 3

Do you currently have, or are you receiving treatment for, any medical conditions or surgeries?

free text

Have you ever had any of the following?

Have you taken any of the following recreational drugs within 6 months; poppers, amyl, butyl nitrates, methamphetamine, meth, cocaine, MDMA or ecstasy?

Have you tried traditionally available medication for erectile dysfunction medications?

Which of the following treatments have you used in the past?

Was this effective for you?

Assessment Progress

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