Oral ED Medication Intake Form Template
Oral erectile dysfunction medications include PDE5 inhibitors (sildenafil, tadalafil, vardenafil) and novel compounded formulations. They work by enhancing nitric oxide-mediated vasodilation to support erections. Due to their vascular mechanism, careful screening for cardiovascular disease, bleeding disorders, and concurrent medications is essential. This intake form documents ED and sexual health symptoms and screens for key contraindications before prescribing.
Free Template
Oral ED Medication Intake Form
Form Preview
This is how the form appears to patients. Customize with your practice name and branding.
Your Practice Name
Oral ED Medication Intake Form
1 General Patient Information
Please provide your personal information.
General Patient Information
Please provide your personal information.
First Name
Jane
Last Name
Smith
Date of Birth
—
Can you confirm you are 18 years or older?
Height
e.g. 5'8"
Weight
e.g. 170 lbs
2 Medical History
Please answer all questions as accurately as possible. Your provider will review this information.
Medical History
Please answer all questions as accurately as possible. Your provider will review this information.
Are you actively taking any medications? If so, please list them.
List all current medications, dosages, and frequencies
Do you have any medication allergies? If so, please list them.
List all known drug allergies and reactions
Are you currently being treated or have you been treated for any medical conditions? If so, please list them.
List all current and past medical conditions
Have you had any past surgeries? If so, please list them.
List all surgeries and approximate dates
What is/was your sex assigned at birth?
Male
Emergency contact name and phone number
Name — (555) 000-0000
Mailing address
123 Main St, City, State, ZIP
Any other questions or concerns?
Optional — share anything else you'd like your provider to know
3 Symptoms
Select all symptoms that currently apply to you.
Symptoms
Select all symptoms that currently apply to you.
4 Contraindications
Select all conditions that currently apply to you.
Contraindications
Select all conditions that currently apply to you.
Preview only. Your live form will include your branding and e-signature capture.
Compliance & Regulatory Notes
Review these notes before deploying this form in your practice.
PDE5 inhibitors are FDA-approved for erectile dysfunction. Compounded versions require pharmacy licensure verification. See FDA: https://www.fda.gov/drugs/human-drug-compounding
PDE5 inhibitors are absolutely contraindicated with nitrate medications (nitroglycerin, isosorbide) due to severe hypotension risk. Screen for nitrate use in all patients.
Priapism risk is elevated in patients with sickle cell disease, multiple myeloma, or leukemia. Screen for these conditions before prescribing.
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- Branded intake on your website
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- E-signatures and HIPAA audit trail
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Free 30-minute walkthrough
Sources & References
Frequently Asked Questions
Can oral ED medications be combined with other sexual health treatments?
Combination therapy (e.g., oral PDE5 inhibitor plus PT-141) is used in some clinical protocols. Provider evaluation of drug interactions and cardiovascular safety is required before combining therapies.
Why is vision a screening concern for ED medications?
Rare but serious visual side effects including non-arteritic anterior ischemic optic neuropathy (NAION) have been reported with PDE5 inhibitors. Patients with pre-existing eye conditions or vision problems require additional evaluation.