Erectile Dysfunction/Hypogonadism Evaluation Note

Date: [Encounter date]
Patient: [Patient name]
DOB: [Date of birth]
Encounter Type: [new / follow-up]; [in-person / telehealth]
Historian: [Historian name/role and reliability]
Chaperone: [Name and role / declined / not applicable] (Document if genital, breast, or DRE exam performed.)

Chief Complaint

[Reason for visit in one line; include brief patient quote only if it clarifies presentation]

History of Present Illness

[Presenting problem summary] (Open with why the patient is here and the primary concern.)

[Erectile dysfunction symptom details] (Include onset [sudden / gradual], duration and course, severity, situational vs generalized, rigidity and ability to sustain erection, presence/quality of morning/nocturnal erections, associated issues with libido/arousal/ejaculation, penile curvature or plaques if present.)

[Prior ED therapies and response] (Document oral PDE5 inhibitors tried with agent, dose, number of attempts, timing relative to intercourse, need for stimulation, technique, and adverse effects; vacuum device experience; intraurethral/intracavernosal therapy history including priapism episodes. Include reasons for discontinuation or barriers to use.)

[Validated instrument score] (Include SHIM/IIEF-5 score and date if obtained. Omit if not used.)

[Symptoms suggestive of hypogonadism] (Include reduced libido, reduced morning erections, fatigue, mood changes, reduced muscle mass/strength, increased adiposity, hot flashes, breast tenderness/gynecomastia, infertility concerns. Include any prior testosterone or anabolic steroid use, including non-prescribed. Omit if hypogonadism not suspected.)

[Psychosocial context] (Include performance anxiety, mood symptoms, relationship factors, recent stressors only as relevant to care; document sensitively and succinctly. Omit if not contributory.)

Sexual and Reproductive History

(Include when STI risk assessment is relevant or fertility-impacting therapies are being considered. Omit section if not applicable.)

• [Partner status and relevant sexual practices] (Use neutral, nonjudgmental language; include protection methods and STI testing history only if relevant to care.)
• Fertility intentions: [near-term / future / none / unclear] (Required before testosterone therapy discussion. Note any prior fertility evaluation. Document counseling that exogenous testosterone can suppress spermatogenesis.)

Cardiovascular and Metabolic Risk Assessment

(Required when prescribing ED medications or advising on sexual activity safety.)

• [Known cardiovascular disease] (CAD, prior MI/revascularization, angina, heart failure, arrhythmias, stroke/TIA, PAD.)
• [Current cardiovascular symptoms] (Chest pain, exertional dyspnea, syncope/presyncope, palpitations, exercise limitation.)
• [Major risk factors and current control] (Hypertension, diabetes, dyslipidemia, smoking, obesity, OSA with CPAP adherence if applicable.)
• [Functional capacity] (Patient-reported ability to climb 2 flights of stairs, walk a mile, or equivalent; include stress test results if available.)

Safety-Critical Medication Interactions (Do not infer; document explicitly.)

• Nitrates (including PRN or recreational nitrites/"poppers"): [Yes / No / Unknown]
• Riociguat or other guanylate cyclase stimulators: [Yes / No / Unknown]
• Alpha-blocker use: [Yes: agent / No]
• Anticoagulant use: [Yes: agent / No] (Relevant if considering injection therapy.)

Cardiovascular risk for sexual activity: [low / intermediate / high]. Additional cardiac evaluation needed before ED therapy: [Yes / No]. [Brief rationale based on history, functional capacity, and testing]

Medical History

• [Endocrine conditions] (Pituitary disease, thyroid disease, diabetes, hemochromatosis.)
• [Neurologic conditions] (Peripheral neuropathy, spinal cord/pelvic nerve injury.)
• [Urologic history] (BPH/LUTS, prostatitis, Peyronie disease, pelvic surgery or radiation, prostate cancer treatment.)
• [Psychiatric history] (Depression, anxiety, substance use disorders.)
• [Conditions predisposing to priapism] (Include if considering injection therapy.)

Medications

• [Current medications] (Reconciled list; include doses if pertinent.)
• [PDE5 inhibitors previously/currently used] (Agent, dose, response, adverse effects.)
• [Medications associated with ED/hypogonadism] (SSRIs/SNRIs, antipsychotics, opioids, 5-alpha reductase inhibitors, certain antihypertensives.)
• [Testosterone products or anabolic steroids] (Prescribed or non-prescribed; route, dose, duration.)
• [Supplements marketed for sexual performance]
• [Substance use] (Tobacco/nicotine, alcohol quantity, cannabis, stimulants; explicitly document nitrite/"poppers" use if not recorded above.)

Review of Systems

(Include only systems reviewed; omit others.)

• [Cardiovascular] (Exertional chest pain, dyspnea, palpitations, syncope.)
• [Endocrine] (Energy, temperature intolerance.)
• [Genitourinary] (LUTS, urinary symptoms.)
• [Neurologic] (Sensation changes, weakness.)
• [Psychiatric] (Mood, anxiety, anhedonia.)
• [Sleep] (Sleep quality, OSA symptoms, CPAP use.)

Physical Examination

• Vital signs: [BP, HR, BMI and/or waist circumference when assessing CV risk]
• General: [Appearance]
• Cardiovascular: [Exam findings]
• Pulmonary: [Exam findings]
• Genital exam: [Penile inspection for lesions/plaques/curvature; testicular size and consistency; varicocele if relevant] (Document chaperone presence or patient declination.)
• Secondary sex characteristics: [Body hair distribution, gynecomastia] (Include if hypogonadism suspected.)
• Prostate/DRE: [Findings] (Include only if indicated; otherwise note reason deferred.)
• Peripheral vascular/neurologic: [Findings as relevant to etiology]

Data Review

• Labs reviewed today: [Fasting glucose or HbA1c, lipid panel, early-morning fasting total testosterone; free/calculated free testosterone if total borderline or SHBG-altering conditions suspected; LH/FSH for primary vs secondary classification; prolactin if secondary suspected; PSA if indicated]
• Labs ordered today: [Tests ordered with timing instructions such as early AM, fasting]
• Imaging/diagnostics reviewed: [Completed tests]
• Imaging/diagnostics ordered: [E.g., penile duplex ultrasound, pituitary MRI; include brief rationale]
• Outside records: [Reviewed / obtained / pending; specify source and dates]

Assessment

Erectile Dysfunction

[Severity/status; include SHIM/IIEF-5 if available]. [Likely contributors: vasculogenic/metabolic, medication-related, psychogenic, hormonal, neurogenic, structural, post-treatment]. [Key supporting evidence]. (If vasculogenic etiology suspected, include brief statement linking ED to CV risk and note plan for further CV assessment or referral.)

Testosterone Deficiency/Hypogonadism

(Include if applicable.) [Diagnostic status: symptoms/signs consistent with deficiency AND low testosterone confirmed by appropriately timed repeat testing, or confirmation pending]. [Classification: primary vs secondary if LH/FSH available; otherwise pending]. [Fertility status as documented].

Other Problems Impacting Management

(Include as applicable.)

• [Problem]: [Status/severity] — [Impact on ED/hypogonadism management]

Plan

Erectile Dysfunction Management

• Reversible factors addressed: [Lifestyle counseling on exercise, weight management, smoking cessation, alcohol moderation]; [Comorbidity optimization and coordination with PCP/specialists as needed].
• Therapy options discussed: [oral PDE5 inhibitor / vacuum device / intraurethral therapy / intracavernosal injection / surgical options / counseling or sex therapy]. [Patient preferences and constraints]. [Contraindication screen results: nitrates/riociguat status, CV risk category].
• If initiating PDE5 inhibitor: [Agent and dose]. (Counsel on timing, need for stimulation, expected efficacy; common adverse effects; strict nitrate contraindication and instructions if chest pain occurs; hypotension risk with alpha-blockers and alcohol; when to seek urgent care for priapism or sudden vision/hearing changes.)
• If initiating vacuum device: [Training provided], [Contraindications reviewed], [Realistic expectations discussed].
• If initiating intraurethral or intracavernosal therapy: [In-clinic titration/training plan and dose used], [Hypotension/syncope precautions], [Priapism threshold and emergency instructions], [Fibrosis monitoring plan for injections], [Bleeding risk precautions if anticoagulated].
• Follow-up: [Timeframe for reassessment], [Plan to measure response via SHIM/IIEF-5 or patient-stated goals].

Cardiovascular Risk Management

• Risk category and basis: [low / intermediate / high] — [Concise rationale].
• Additional evaluation/referral: [Stress testing / cardiology referral / none needed].
• Risk factor optimization: [BP, lipids, diabetes, OSA adherence, smoking cessation] with [PCP/cardiology coordination plan].
• Patient instructions: [What to do if cardiac symptoms occur during sexual activity or after ED medication use].

Hypogonadism Evaluation/Treatment

(Include if applicable.)

• If diagnosis not confirmed: [Order early-morning fasting total testosterone on a separate day]; [Add free/calculated free testosterone if indicated]; [LH/FSH and prolactin if low T confirmed or secondary suspected]; [Assess reversible contributors: obesity, OSA, opioids, acute illness].
• If considering testosterone therapy: [Indication: symptoms plus confirmed low testosterone]. [Fertility status and counseling documented—required before initiation]. [Contraindication screen: prostate/breast cancer history, baseline PSA, hematocrit, recent major CV events, untreated severe OSA, severe LUTS]. [Formulation selected with rationale]; [Transference precautions if topical].
• Monitoring plan if starting/continuing testosterone: [Symptom response and adverse effects at follow-up], [Testosterone level at 3–6 months, 12 months, then annually once stable], [Hematocrit monitoring with action thresholds], [Prostate monitoring/PSA schedule per shared decision-making], [Criteria for discontinuation if no benefit or adverse effects].

Orders

• Labs: [Tests with timing instructions such as early AM, fasting]
• Prescriptions: [Agent, dose, quantity, refills; confirm counseling documented above]
• Referrals: [Urology, cardiology, endocrinology, sex therapy/counseling, sleep medicine as appropriate]
• Patient education: [Handouts provided, after-visit summary topics]

Return Precautions

• Seek urgent care for chest pain, syncope, or severe dyspnea during sexual activity.
• For erection lasting >4 hours (priapism), seek emergency evaluation immediately.
• Seek care urgently for sudden vision or hearing loss.
• Contact clinic for adverse medication effects, inadequate response, or questions about therapy.