Medical Assessment

To help us supply you with the most suitable treatment, please complete this online consultation.

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About You

Are you male and aged between 18-75?

Yes

We are unable to supply you with medication for erectile dysfunction. Please consult your GP.

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Do you smoke or drink?

Yes

You are eligible for treatment, however, be aware alcoholic drinks and/or smoking can make erection difficulties worse. Consult your GP for information on giving up smoking.

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Have you taken Viagra (sildenafil), Levitra (vardenafil), Nipatra, Spedra or Cialis (tadalafil) at least 4 times previously without any side effects?

Yes

As you have not previously taken any erectile dysfunction medication, we will not be able to supply you with a high strength treatment as you must try a standard strength first.

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Your Symptoms

Do you have trouble achieving or maintaining your erection?

Yes

It does not appear that you have erectile dysfunction. We are unable to supply you with treatment. Please consult your doctor for more information.

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Your Health

Do you have any allergy to Viagra (sildenafil), Levitra (vardenafil), Spedra (avanafil) or Cialis (tadalafil) or have you experienced any adverse reaction to any erectile dysfunction medication previously?

Yes

We are unable to supply you with treatment. Please consult your doctor for more information.

Please complete this question.

Do you have high blood pressure (above 160/90), or are you currently on treatment for high blood pressure?

If you do not know your blood pressure you can have this measured at your local pharmacy/GP surgery.

Yes

We are unable to supply you with treatment if you have high blood pressure. Please consult your GP for more information.

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Do you have low blood pressure (below 90/50)?

If you do not know your blood pressure you can have this measured at your local pharmacy/GP surgery.

Yes

We are unable to supply you with treatment if you have low blood pressure. Please consult your GP for more information.

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Do you suffer from depression for which you have not seen a GP?

Yes

We are unable to supply you with treatment at this time. Please consult your GP.

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Have you been advised to avoid strenuous exercise?

Yes

We are unable to supply you with treatment. Please consult your GP for more information.

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Have you ever suffered from any of the problems listed below?

Any heart problems including angina, chest pain, heart failure, irregular heart beats, heart attack (myocardial infarction), left-ventricular outflow obstruction, cardiomyopathy or valvular heart disease (e.g.aortic stenosis).
Stroke
Sight loss due to poor circulation
Sight loss because of non-arteritic anterior ischemic optic neuropathy (NAION)
Blood problems such as haemophilia, sickle cell anaemia (an abnormality of red blood cells), leukaemia (cancer of blood cells)
Stomach ulcers (e.g. peptic/gastric ulcer)
Liver problems
Kidney problems
An erection that lasted more than 4 hours
Any physical condition affecting the shape of the penis (e.g. angulation, Peyronie’s disease and cavernosal fibrosis)
Inherited eye disease - retinitis pigmentosa
Multiple myeloma (cancer of the bone marrow)
Galactose intolerance, Lapp Lactase deficiency or glucose-galactose malabsorption
Any serious medical condition which may require immediate hospitalisation

Yes

We are unable to supply you with treatment. Please consult your GP.

Please complete this question.

Would you have any difficulty walking at a fast pace for 5 minutes?

Yes

We are unable to supply you with treatment at this time. Please consult your GP.

Please complete this question.

Your Medication

Are you currently taking any medication (including over the counter, prescription or recreational drugs)?

Yes

Are you taking any of the following medications?

Any treatment for erectile dysfunction apart from Viagra (sildenafil) , Levitra (vardenafil) or Cialis (tadalafil), Spedra (avanafil)
Medicinal nitrates such as glycyryl trinitrate, isosorbide mononitrate or isosorbide dinitrate (including oral, transdermal and sublingual)
Recreational drugs prohibited by law (Class A,B or C)
Recreational nitrates such as amyl nitrate also known as "poppers"
Alpha blockers (used to treat high blood pressure or urinary symptoms associated with benign prostatic hyperplasia, and including tamsulosin, doxazocin, prazocin terazocin & indoramin)
Medicines to treat high blood pressure.
Warfarin - used to to prevent heart attacks, strokes, and blood clots
Anti-virals including (Atazanavir, etravirine, fosamprenavir, indinavir, nelfinavir, ritonavir, saquinavir)
Nicorandil
Anti-fungal medication such as Ketoconazole or itraconazole
Quinidine/procainamide/amiodarone
Theophylline
Erythromycin/clarithromycin/cimetidine
phenobarbital, phenytoin and carbamazepine (anticonvulsant medicines).
Riociguat
Rifampicin

Yes

We are unable to supply you with treatment. Please consult your GP.

Please complete this question.

Are you taking any medicines known as nitrates (often taken for chest pain/angina) or nitric oxide donors ('poppers')?

Often taken for chest pain/angina
Can be administered as a spray, tablet or patch.
Include glyceryl trinitrate, isosorbide mononitrate or isosorbide dinitrate

Yes

We do not advise any recreational drug use with PDE 5 inhibitors, but especially nitric oxide donors such as ‘poppers’ which may lead to a dangerous fall in your blood pressure. We are unable to supply you with treatment. Please consult your doctor for more information.

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Agreement

Do you understand that erectile dysfunction can be associated with a number of contributing conditions eg hypertension, diabetes mellitus, high cholesterol or cardiovascular disease and you should consult your doctor within 6 months of starting treatment for a clinical review?

Yes

You must agree to this before continuing. If you need assistance contact customer support.

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I agree that in the rare event I obtain a prolonged erection of more than 4 hours, I will seek immediate medical assistance.

Yes

You must agree to this before continuing. If you need assistance contact customer support.

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Do you agree to the following?

You will read the patient information leaflet supplied with your medication
You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment.
The treatment is solely for your own use
You have answered all the above questions accurately and truthfully. You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health
You understand that whilst decisions relating to your treatment are made jointly between you and the prescriber, the final decision to issue a prescription will always be with the prescriber.

Yes

You must agree to this before continuing. If you need assistance contact customer support.

Please complete this question.

Medical Assessment

To help us supply you with the most suitable treatment, please complete this online consultation.

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