Trimix Refill Questionnaire Template

A clinical follow-up questionnaire for patients refilling a penile injection prescription (Bimix, Trimix, Quadmix, or custom formulations). Captures prior formulation details, satisfaction, current dosing, erection quality metrics, and safety screening for priapism risk management. Designed to give prescribers the data needed to safely renew or adjust penile injection therapy.

4 sections
9 fields
HIPAA-ready
3 citations

Free Template

Trimix Refill Questionnaire

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Penile Injection (Trimix / Bimix) Intake Form

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Your Practice Name

Trimix Refill Questionnaire

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1

Prior Prescription History

Tell us about your previous penile injection prescription.

Have you been prescribed penile injections before for Erectile Dysfunction?

Yes
No

What was your previous formulation?

Bimix

2

Treatment Satisfaction

Help us understand how your current therapy is working.

Are you satisfied with your results while on your current penile injection formula?

Yes
No

If not satisfied, please explain.

Describe what is not working as expected...

What is your current draw amount?

5 units

3

Erection Quality

Please answer the following about the quality of your erections on therapy.

What is your erection firmness while on Trimix? (1 = very soft, 10 = fully rigid)

1

What is your average erection duration while on Trimix?

Less than 30 minutes

4

Side Effects and Safety

Your safety is our top priority. Please answer the following carefully.

Have you experienced any side effects? If yes, please explain.

Describe any side effects, pain, bruising, or unusual reactions...

Do you have phenylephrine on hand in case your erection lasts longer than 3 hours?

Yes
No

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Compliance & Regulatory Notes

Review these notes before deploying this form in your practice.

Prescribers must ensure patients have phenylephrine (or equivalent) available and understand the priapism protocol before renewing penile injection therapy. Erections lasting more than 4 hours require emergency treatment. See AUA Erectile Dysfunction Guidelines: https://www.auanet.org/guidelines-and-quality/guidelines/erectile-dysfunction-guideline

Dose escalation or formulation changes should be based on reported firmness (target 7-8/10) and duration (target under 60 minutes). Erections lasting 2 or more hours at current dose indicate the draw amount should be reduced before renewal.

Custom compounded penile injection formulations must be prescribed through a licensed 503A compounding pharmacy. Document the prescribing rationale for any formulation outside standard Trimix. See PCAB compounding standards: https://www.pcab.org/accreditation/

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Sources & References

  1. AUA Erectile Dysfunction Clinical Guidelines
  2. PCAB Compounding Pharmacy Accreditation Standards
  3. FDA Alprostadil (Caverject) Prescribing Information

Frequently Asked Questions

What is the difference between Bimix, Trimix, and Quadmix?

Bimix contains two vasodilating agents (typically papaverine and phentolamine). Trimix adds alprostadil (prostaglandin E1) for enhanced efficacy. Quadmix adds a fourth agent such as atropine or forskolin. Higher-combination formulas are typically used for patients who do not respond adequately to simpler formulations.

What should a patient do if their erection lasts more than 3 hours?

An erection lasting more than 3-4 hours (priapism) is a medical emergency. Patients should inject phenylephrine intracavernously per their provider's instructions, or go to the nearest emergency room immediately. All penile injection patients must have phenylephrine available and understand this protocol before starting therapy.

How is the draw amount adjusted between refills?

If firmness is below 7/10 and duration is under 45 minutes, the prescriber may increase the draw amount by 5 units. If firmness is adequate but duration is approaching or exceeding 2 hours, the draw amount should be reduced. Adjustments are made conservatively to minimize priapism risk.