Medical Assessment for Erectile Dysfunction

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 between 18 and 75 years of age?

Yes

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

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Do you smoke or drink?

Yes

You are eligible for treatment, however, be aware that consuming alcoholic drinks and/or smoking can make erectile dysfunction worse.

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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. You must try a standard-strength treatment at least 4 times to be eligible for a high-strength treatment.

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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 GP or 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 GP or doctor for more information.

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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 or doctor 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 or doctor 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 or doctor for more information.

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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 or doctor 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 heartbeats, 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) or leukaemia (cancer of the 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, or cavernosal fibrosis)
An inherited eye disease such as retinitis pigmentosa
Multiple myeloma (cancer of the bone marrow)
Galactose intolerance, Lapp lactase deficiency or glucose-galactose malabsorption
Any serious medical condition that may require immediate hospitalisation.

Yes

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

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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 or doctor.

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Your Medication

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

Yes

Are you taking any of the following?

Any other erectile dysfunction treatments that are not Viagra (sildenafil), Levitra (vardenafil), Cialis (tadalafil), Spedra (avanafil)
Medicinal nitrates such as glycerol 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 (such as tamsulosin, doxazosin, prazosin, terazosin or indoramin) used to treat high blood pressure or urinary symptoms associated with benign prostatic hyperplasia
Medicines to treat high blood pressure
Warfarin - used to prevent heart attacks, strokes, and blood clots
Antiviral medications, including (Atazanavir, etravirine, fosamprenavir, indinavir, nelfinavir, ritonavir or saquinavir)
Nicorandil
Anti-fungal medication such as ketoconazole or itraconazole
Quinidine, procainamide or amiodarone
Theophylline
Erythromycin, clarithromycin or cimetidine
Phenobarbital, phenytoin or carbamazepine (anticonvulsant medicines)
Riociguat
Rifampicin.

Yes

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

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
Includes glyceryl trinitrate, isosorbide mononitrate or isosorbide dinitrate.

Yes

We do not advise any recreational drug use with PDE 5 inhibitors, 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 GP or doctor for more information.

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Agreement

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, you start new medication and/or 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 our customer support.

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Do you understand that erectile dysfunction can be associated with a number of contributing health conditions (e.g. 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, please contact our customer support.

Please complete this question.

In the rare event I obtain a prolonged erection of more than 4 hours or experience any sudden visual impairment, I agree that I will seek immediate medical assistance.

Yes

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

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Medical Assessment for Erectile Dysfunction

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

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